period and (2) we will credit any payment applied toward Purchases as of the first day in your current billing period if you make a payment by the Paytnent Due Date in the current billing period that ks less than the Statement Balance. If a Statement Balance was shown on your previous billing statement

tact Person Ntimber 90 zoq - /041- "7 7. Witness Name& , agm a one • t. tyl,c sfh #, SSN Ma . & Vendor Name & Address, Phone it, TIN/S$N 9. Paytnent to hepatic' to: a M- 10. Recsiptfinvolce Is: 11. Type of Unusual Expense: Medically Necessary Item (Attached SuppodIng Statement) lapopendeet C