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•MISCELLANEOUS BILLING REQUEST FORA) <br /> ORIGINATOR'S NAME /EW# Lowen/ 2294 EXT 7443 DATE 2/04/2013 <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 \lit) (..") <br /> SSN OR TIN /EIN# t <br /> REFERENCE INFORMATION p <br /> FULL LEGAL NAME, RELATIONSHIP <br /> COMPLETE ADDRESS <br /> PHONE(HOME, BUSINESS,CELL) <br /> BUSINESS INFORMATION <br /> ei V <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 /> 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 SLH2 AMOUNT TO BILL -$7.71 <br /> RATE TO BE USED Increase SLH1 AMOUNT TO BILL $5.15 <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 Jim Riggs @ COE repl (1) 200 W HPS S/L @ 24 /Monroe EWEB Pole 10742 w/ (1) 100 W HPS effective 1/18/2013 <br /> BILLING CONTROL USE ONLY <br /> DATE RECEIVED DATE ENTERED <br /> ENTERED BY CYCLE NUMBER <br /> ACCOUNT # ADJUSTMENT # <br />