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IN <br />BILLING INFORMATION <br />PLEASE COMPLETE THIS FORM AND RETURN WITH DOCUMENTS <br />In order for DE LAGS LANDEN PUBLIC FINANCE L -- m to properly bill and credit your account, it is necessary that you <br />complete this form and return it with the signed documents. <br />Billing Name . CITY OF SOUTH BEND, INDIANA Aft)l D� �, 0Loy1 t O./'— <br />If you would like your invoices emailed to you in place of regular mail, please provide an email address(es) below: <br />Billing Add <br />*YOUR INVOICES WILL BE EMAILED FROM INVOICEDELIVERY@PAYEREXPRESS.COM <br />1 ge'v hill <br />Attention: 0a+w * -.. f. .,,....... ..... <br />Telephone Number:. o <br />FEDERAL IDfi:. ..................-------- <br />SPECIAL INSTRUCTIONS <br />Do you require a Purchase Order Number on the invoice? If yes, please provide PO# . <br />Is a new purchase order required for each new fiscal period? <br />If yes, provide month/year PO expires...... <br />Are you sales tax exempt? If yes, please attach a copy of exempt certificate or direct pay permit. lwae,/r<g'a'� <br />Do you require any special information to establish a vendor number for ......... <br />If yes, please advise:. W------- -......... <br />Additional Comments: .... <br />CONTACT INFORMATION AND QUESTIONNAIRE FOR FORM 8038-G FILINGS <br />(required for all Stale and Local Government transactions) <br />Contact Nanne. OA.h P11-e-1 <br />Contact Address: R'M <br />Contact Telephone Number ",.X�"" <br />Email Address: doa r re.r-c <br />NI Irrfa 11il- <br />❑ YES <br />A NO <br />❑ YES <br />& NO <br />SYES <br />❑ NO <br />? X] YES <br />❑ NO <br />M you have further questions, please consult your regular bond or legal counsel. <br />02016 All Rights Reserved.. Printed in the 11.S.A, 16PFnnG272 11/16 <br />