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GC-.-CRfG4)34f C(Pf 3)0-CC(1(/))f ,230f abCRefb4 ESA Name of Utility Services Provider: _ Type of Utility Service(s): _ MDNc.m gTRS].m dSVSaT][S.m EbSaNTRm Ojm aSb/ESg3mN[RmINi3mD]RSm GSP3m C8565*%A-lm Company FEIN No.: _ Remitted by ACH: _ :NFfoOTHU_S;_OUTfo _N;_fo dU_fo __UaOEFfo OTfo _NO_fo _FSO__;TDFfo HU_Sfo bORRfo CFfo S;OT_;OTFEfo ;_fo DUTIPEFT_O;Rfo _TEF_fo 6Fa)fo ;TEfo:;cfo 4UEFffo/-2-).)fo ityqp4 ityquq§§4 Suqo ytot 34 Tm§4 gquqoxv4 gquqoxv4 im qy4 gm24 9x1qyqp.4 Tyx§§4 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Pqp0o txw§4 0.00 0.00 0.00 0.00 0.00 0.00 0.00 iS2qvy 48oox0w §l4 axw0f 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8pty0§ vqw aq 4gm2mnuq4 0.00 0.00 0.00 0.00 0.00 0.00 gm24 cqyoqw mrq4 6,4 6,4 417,4 417,4 414,4 3,4 6,4 8yyutqp4 cqwmu tq§4 0.00 0.00 0.00 0.00 0.00 0.00 0.00 aw qyq§ 4 0.00 0.00 0.00 0.00 0.00 0.00 0.00 gx mu4 dqvt mwoq4 AAAAC AAAAC 0.00 0.00 0.00 0.00 AAAAC Remit to: City of Modesto Attn: Cashiering Dept. - UUT P.O.Box642 Modesto, Ca. 95353 5RF;_Ffo TU_F(fo ;RRfo _;cF_fo DURRFD_FEfo E__OTMfo ;TdfoMOaFTfo SUT_Nfo S___fo CFfo _FDFOaFEfo Cdfo _NFfo 4O_fo TUfo R;_F_fo _N;Tfo _NFfo -*foEBefo UHfo _NFfo HURRUbOTMfo SUT_N)fo 5FT;R_OF_fo ;TEfoOT_F_F__fo bORRfo CFfo OS_U_FEfo UTfo EFROT__FT_fo _AeSFT__)fo 9FFfo 9FDfo 2)-)fo 3,-fo *Please prepare a separate remittance form for each tax period; do not combine tax periods. **Please describe any non-standard adjustments: _ I declare, under penalty of perjury, that to the best of my knowledge and belief the statement herein, and any attachments hereto, are true and correct. Date: _ Phone: _ Signed: _ Print Name/Title: _ Address: