VABillJan97Post
Department of Veterans Affairs Fiscal Service
VA Medical Center Lyons 151 Knollcroft Rd. Lyons, NJ 07939-9998
(908-647-0180) EXT6413
Acct No.: 123456789
Due Before: JAN 11, 1997 AM8unt Due: $129.86
Amount Paid: _____________ Today's Date: Dec 11, 1996
Please Make your Check or Money Order payable to the "Department of Veterans Affairs" and send payment to the above address. If you have any questions regarding this statement, please call the number listed above.
Raab James. Forest Ave. Harbor, NJ 08879
(201)676-1000 X1279 For Mastercard and visa payments.
1(800)382-4156 FOR ALL other calls.
Please Detach and Return Top Portion with Payment
IMPORTANT: Please read the Notice of Rights accompanying this statement!
Department of Veterans Affairs Raab, James Acct No.: 123 45 6789 Page 1
:10/11/96 :Previous Balance : 539.35
:10/25/96 OUTPATIENT CARECNSC) -41.00561-K667984
:10/25/96 OUTPATIENT CARECNSC) -41.00561-K677598
:10/25/96 OUTPATIENT CARECNSC) -41.00561-K677598
:10/25/96 OUTPATIENT CARECNSC) -41.00561-K677598
:10/25/96 OUTPATIENT CARECNSC) -41.00561-K677598
:10/25/96 OUTPATIENT CARECNSC) -41.00561-K687445
:10/25/96 OUTPATIENT CARECNSC) -41.00561-K687445
:10/25/96 OUTPATIENT CARECNSC) -41.00561-K687445
:10/25/96 OUTPATIENT CARECNSC) -41.00561-K687445
:10/25/96 OUTPATIENT CARECNSC) -41.00561-K687445
:10/30/96 :INTEREST/ADM. Int/CHARGE -1.39:561-K677598
:11/12/96 :INTEREST/ADM. Int/CHARGE -0.93:561-K667984
:11/12/96 :INTEREST/ADM. Int/CHARGE -0.01:561-K682793
:12/11/96 :INTEREST/ADN. Int/CHARGE -0.95:561-K667984
:12/11/96 :INTEREST/ADM. Int/CHARGE -0.01:561-K682793
Previous Balance $539.35, Interest Charges $1.90, Payment $411.39, Balance $129.86
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