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April 25, 2024

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Invoice Number:142658
Billing Period:01/01/2007 - 01/31/2007

Vision Group Number:40001-000-00000-00000
Group Name:VISION
Master Number:40001
Description: 
Phone Number:(999) 999-0000

VISION
GILLIAN MYER
VP SECRETARY
2245 BLUE JAY WAY
ANYWHERE, USA 55555-0000

STATEMENT OF ACCOUNT
Billing Period: 01/01/2007 - 01/31/2007
Due Date: 01/01/2007

Prior Due
 Prior Amount Due$62.20 
 Less Payment Received 62.20 
 Balance From Prior Billing .00 
 
Current Due
 Total Subscriber Adjustments$9.72 
 Current Billed 62.20 
 Balance From Current Billing 71.92 
 
Total Amount Due
 Total Amount Due$71.92 
     

Please make checks payable to: DELTA DENTAL

Payments and changes not reflected on this invoice will appear on the next invoice.

PLEASE RETURN THIS STATEMENT OF ACCOUNT PAGE WITH YOUR PAYMENT.

 
Group Name: VISION
Vision Group Number: 40001-000-00000-00000
 
Vision Amount Due: $ 71.92  
Vision Amount Submitted: $ ______________________________________
 
Signature:  
 

Please send all remittance to:
DELTA DENTAL
PO BOX 999
ANYWHERE USA 55555