Rix i:-.1a1 Total Amount Claimed By Financial Institution 14 1 certify that the articles and services listed woe received: 16 Disallowance (See Aaaehal 17 Net to Financial Institution 18 Right to Financial Privacy Act - Public Law 95-630 (12 U.S.C. 3401-3422) Request Pursuant To: (Check Are Ony)