Fillable Printable Sample Account Statement

Sample Account Statement

Service Address

Next statement date

Account number

Total of last

account

Processed since

last account

Balance brought

forward

New

charges

NewWorld Company

PIONEER VALLEY REGION

☎ 999 9999 − ACCOUNT ENQUIRIES 8:30AM TO 4:30PM

☎ 999 8888 − SERVICE ENQUIRIES 8:00AM TO 5:00PM

PAYMENT SLIP

Automatic Account Payment:

to apply contact 999 9999or any New World Store.

Paying by Mail:

Detach this payment slip.

Make checks out to: NewWorld Medical Association.

In Person:

Present this account intact at your

local NewWorld Store

Please do not pin or staple check to payment slip.

Mail both to: GPO BOX 100, Globecity 1000.

Total amount due

+ =

3035[MV−7]

NOTE: This is not a bill, just a recap of your account. If you wish to make a payment, please use the payment slip below.

DATE:__________________

STATEMENT

544SI

Acct. No.

Over 90 Days61−90 Days31−60 Days1−30 DaysCurrent

$43.95$0.00$0.00$0.00$0.00

544SI

IS00126630 19−MAY−04 Invoice 18−JUN−04 ICABR2926

PART NUMBER DESCRIPTION/DETAIL REFERENCE

HURLBURT

131 LOOP ROAD BLDG 91042

HURLBURT FL 32544

16TH STREET MEDICAL GROUP : FIELDBT1

131 LOOP ROAD BLDG 91042

HURLBURT FL 32544

544SI

−JAN−05

$43.95