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• <br /> •ISCELLANEOUS BILLING REQUEST FORM • <br /> ORIGINATOR'S NAME /EW# Lowen/ 2294 EXT 7443 DATE 11/07/2012 <br /> NEW ACCOUNT SETUP ❑ ADJUSTMENTS & CHARGES El <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 /> CS <br /> REFERENCE INFORMATION n � <br /> FULL LEGAL NAME, RELATIONSHIP Y Nif <br /> COMPLETE ADDRESS v \ <br /> i ! <br /> PHONE(HOME, BUSINESS,CELL) <br /> BUSINESS INFORMATION <br /> TYPE OF BUSINESS (COPR, LLC, ETC.) <br /> OWNERS LEGAL NAME & SSN <br /> ACCOUNTS PAYABLE 4) <br /> PARTNERS (FULL LEGAL NAMES & SSN ` L <br /> CORPORATION OFFICERS <br /> TITLE, FULL LEGAL NAME(S) \I <br /> ADDRESS \ �" <br /> PHONE (HOME, BUSINESS, CELL) VVV�" O (� <br /> (\) <br /> Y ) <br /> BANK INFORMATION 1 ✓ <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 SLH 4 AMOUNT TO BILL - 13.05 X 1= -13.05 <br /> RATE TO BE USED Increase SLH2 AMOUNT TO BILL 7.71 x 1= $7.71 <br /> RATE TO BE USED Decrease SLH5 AMOUNT TO BILL -$3.50 <br /> ACCOUNT NUMBER 23736 -142 BUNCH CODE TO BE USED <br /> NOTES (REASON FOR ADJUSTMENT, ETC.) <br /> Per Jim Riggs @ COE repl (1) 400 W HPS S/L @ 777 High St COE pole 27891 w/ (1) 200 W HPS and Delete (1) SOW HPS S/L <br /> @ 740 Alder Aley EWEB pole# 3491 effective 10/19/2012 <br /> BILLING CONTROL USE ONLY <br /> DATE RECEIVED 11 -7 -12 DATE ENTERED 11 -7 -12 <br /> ENTERED BY EW2036 CYCLE NUMBER 01 <br /> ACCOUNT # 23736 -142 ADJUSTMENT # 100423970 <br />