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<br />..'. <br /> <br />FACT SHEET <br />PLEASE hdURN THIS SHEET WITH THE FIN;.....CIAL STATEMENTS <br /> <br />......, <br /> <br />.', <br />", <br /> <br />" <br /> <br />-. <br /> <br />..... <br /> <br />PROPOSAL NUMBER: <br />LEGAL NAME 01= ENTIlY: <br /> <br />DEPARTMENT USING EQUIPMENT' <br /> <br />FEDERAL 10 NUMBER: <br /> <br />NAME OF COUNTY: <br /> <br />STREET ADDRESS: <br /> <br />Please give complete physical street address. 00 not give <br />address with P.O. Box as express delivery will not deliver <br />to it, <br /> <br />BILUNG ADDRESS: . <br /> <br />Please indicate any special billing instructions that are <br />required to avoid late payments and subsequent late <br />charges. <br /> <br />ACCOUNT PAYABLE: <br />CONTACT <br /> <br />SIGNATURES: <br /> <br />TELEPHONE II' <br /> <br />Pleue print or type names exactly as the person will be <br />signing the document. Signatures are not required here. <br /> <br />AUTHORIZED OFFICIAL: <br />Name: <br />Tltle: <br /> <br />AlTORNEY SIGNING OPINION OF COUNSEL: <br />Name: <br /> <br />TELEPHONE II' <br /> <br />MAJOR REVENUE SOURCE' <br />BANK REFERENCE' <br /> <br />CONTACT NAME: <br /> <br />TELEPHONE ,. <br /> <br />FACT.SM.l'll'" <br />