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Account Number

Locate your account number at the top of your statement.

Date of Birth (Guarantor/Financially Responsible Party)

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Acknowledgement/Attestation (Optional)

I hereby attest, certify and acknowledge, under penalty of perjury, that my current gross household income is less than that set forth in the Federal Poverty Guidelines , as adjusted for my marital status and household size, and that I will send payment of the total billed charges minus 15% on or before: XX/XX/20XX

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