CITY OF MOLINE

P 0 Box 308
Orion, IL 61273-0308
(309)524-5337
866

1-~
30~6~5~~~~~~~~~~~~~~~~~~~~~~

!i~t!~JJ~!~!I;~:~Igit~i~~-, :_, .:l~Jf0.JIII~l~~~l~~{1~~"~}\ ,i~}:~i~t.~t;[0}:~~~~~s}~[~}~~m~:!~]~~~f

CITY OF MOLINE
P 0 Box 308
Orion, IL 61273-0308

Invoice Date

TO ASSURE PROPER CREDIT, RETURN THIS

PORTION WITH YOUR PAYMENT

Ticket#:

MAKE CHECKS PAYABLE TO:

Charges
4/15/2016
4/15/2016
4/15/2016
4/15/2016

04/25/16

Patient ID

AMOUNT PAID

DETACHHERE - - - - - - - - - - - - - - - - - -- ---------------CITY OF MOLINE

BALANCE

$1,125.00
$210.00
$53.30
$19.00

Milage
Supplies
Charge Total :

$1,407.30

BALANCE
We do not have any insurance information on file. Please call or
send us a copy of your insurance cards . If this bill is related to an
auto accident, please send us the claim number, insurance
company, their address and phone number.
If you do not have insurance, we would also be happy to set up a
payment plan that will work for you .
Just give us a call.

$1 ,407.30