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•SCELLANEOUS BILLING REQUEST FORM <br /> ORIGINATOR'S NAME /EW# Aisha Soria/ 2237 EXT 7522 DATE 01/22/2014 <br /> NEW ACCOUNT SETUP ❑ ADJUSTMENTS & CHARGES CE <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 �J f <br /> • <br /> PARTNERS (FULL LEGAL NAMES & SSN <br /> 11 * <br /> CORPORATION OFFICERS �t <br /> TITLE, FULL LEGAL NAME(S) ` `( ( \ / + { I <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- 4 ea AMOUNT TO BILL -$5.55 x 4 = $22.20 <br /> RATE TO BE USED Increase SLH7 - 4 ea AMOUNT TO BILL $4.48 x 4 = $17.92 <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 (4) 100 W HPS S/L @ Crabtree and Timberline (COE P #29385), Shelton and Stansby <br /> (COE P #30631), 2478 Brittany St (COE P #27083) and 3730 Shane Dr (COE P #30159) w/ (4) 70 W HPS effective 1/21/14. <br /> BILLING CONTROL USE ONLY <br /> DATE RECEIVED DATE ENTERED <br /> ENTERED BY CYCLE NUMBER <br /> ACCOUNT # ADJUSTMENT # <br />