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Your Company Name

Street Address Address 2 City, ST ZIP Code Phone: Fax: E-mail: (413) 555-0190 (413) 555-0191 someone@example.com

Statement
Statement #: nter statement number E Date: July28,2011 Customer ID: Enter customer ID Bill To: Name Company Name Street Address Address 2 City, ST ZIP Code

Date

Type

Invoice #

Description

Amount Payment Balance () ()

Reminder: Please include the statement number on your check. Terms: Balance due in 30 days. REMITTANCE Customer Name: Customer ID: Statement #: Date: Amount Due: Amount Enclosed: Enter customer name Enter customer ID Enter statement number July28,2011 $0.00

Total

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