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M ISCELLANEOUS BILLING REQUEST FORA <br /> ORIGINATOR'S NAME /EW# Lowen/ 2294 EXT 7443 DATE 2/04/2013 <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# /(27 <br /> REFERENCE INFORMATION "J <br /> FULL LEGAL NAME, RELATIONSHIP �' / <br /> COMPLETE ADDRESS vvv <br /> PHONE(HOME, BUSINESS,CELL) <br /> BUSINESS INFORMATION � <br /> TYPE OF BUSINESS (COPR, LLC, ETC.) ( <br /> OWNERS LEGAL NAME & SSN \ � 1 <br /> i) r j' <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) V <br /> ■ \(}e) <br /> BANK INFORMATION 114 <br /> BANK NAME \ <br /> • <br /> BRANCH (IE. MAIN BRANCH, EUGENE OR) / <br /> AUTHORIZED PARTIES <br /> Qr <br /> NOTES( CONTRACT 4, JOB #, JOB SPECIFICS, ORDERED BY, ETC.) <br /> ADJUSTMENTS AND CHARGES <br /> RATE TO BE USED Decrease SLH1 AMOUNT TO BILL -5.15 X 4 = -$20.60 <br /> RATE TO BE USED Increase SLH2 AMOUNT TO BILL 7.71 x 4 = $30.84 <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 (4) 100 W HPS S/L @ Traffic signal poles @ River Rd /Silver Lane (all four corners of <br /> intersection) w/ (4) 200 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 />