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• <br /> WA ISCELLANEOUS BILLING REQUEST FORM <br /> ORIGINATOR'S NAME /EW# ASoria /2237 EXT 7422 DATE 12/10/13 <br /> NEW ACCOUNT SETUP ❑ ADJUSTMENTS & CHARGES <br /> ACCOUNT SETUP <br /> CUSTOMER INFORMATION <br /> CUSTOMER NAME City of Eugene <br /> PRESMISES /PROPERTY ADDRESS <br /> MAILING ADDRESS <br /> CONTACT NAME <br /> BUSINESS PHONE# / CELL # <br /> FAX NUMBER <br /> SSN OR TIN /EIN# <br /> REFERENCE INFORMATION <br /> FULL LEGAL NAME, RELATIONSHIP <br /> COMPLETE ADDRESS <br /> PHONE(HOME, BUSINESS,CELL) <br /> BUSINESS INFORMATION <br /> TYPE OF BUSINESS (COPR, LLC, ETC.) <br /> OWNERS LEGAL NAME & SSN <br /> ACCOUNTS PAYABLE <br /> PARTNERS (FULL LEGAL NAMES & SSN <br /> CORPORATION OFFICERS <br /> TITLE, FULL LEGAL NAME(S) <br /> ADDRESS <br /> PHONE (HOME, BUSINESS, CELL) <br /> BANK INFORMATION <br /> BANK NAME <br /> BRANCH (IE. MAIN BRANCH, EUGENE OR) <br /> AUTHORIZED PARTIES <br /> NOTES( CONTRACT #, JOB #, JOB SPECIFICS, ORDERED BY, ETC.) <br /> ADJUSTMENTS AND CHARGES <br /> RATE TO BE USED Decrease SLH1 - 3 ea AMOUNT TO BILL -$5.45 X 3 = -16.35 <br /> RATE TO BE USED Increase SLH7 - 3 ea AMOUNT TO BILL $4.48 X 3= 513.44. <br /> RATE TO BE USED AMOUNT TO BILL <br /> ACCOUNT NUMBER 23736 -142 BUNCH CODE TO BE USED <br /> NOTES (REASON FOR ADJUSTMENT, ETC.) <br /> Per Kris Olson @ COE repl (3) 100 W HPS S/L @ Calumet /Spring Meadow (COE P #98219), 4310 Hilton Dr (COE P #99895), <br /> & 1747 Russet Ave.(COE P# 30155) Effective 11/15/13 <br /> BILLING CONTROL USE ONLY <br /> DATE RECEIVED 12/10/13 DATE ENTERED 12/10/13 <br /> ENTERED BY EW2401 CYCLE NUMBER 01 <br /> ACCOUNT # 23736 -142 ADJUSTMENT # 100423970 <br />