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BILLING INFORMATION <br />Agreement Number: 500-50823891 <br />This form is required for De Lage Landen Financial Services, Inc. to properly bill and credit your account. Please <br />complete this form and return it with the signed documents. <br />ENROLL IN PAPERLESS BILLING! <br />Paperless r Convenient Access your invoices anytime, anywhere, from any device <br />Sign me up for Email Invoicing. Send my invoices to the email address below: <br />EmailAddress(es): et.oun+sPayc►h1e� s13L • iVET <br />NOTE: Your invoices will be emailed from noreply@notices.leasedirect.com. <br />Subject line will be: "Your Lease Direct Invoice is ready to view online!" You will not receive a physical invoice if you elect paperless billing. <br />Billing Name: City of Sunny Isles Beach Phone: -3Q1j • 1-C Z —I +0-f <br />Customer Contact Email (if different from above): / <br />Billing Address: I `7O CColli n5 Aven vIP AMdyl� �A�/e�OG <br />v <br />StreetAddmesa or PO Box Attention <br />Sonrlu kle-, 34ach IGo <br />city <br />FEDERAL TAX ID #: D?$ 0 (gypY 7 <br />Accounts Payable Contact Information (if different from above): <br />State <br />Name: Email: Phone: <br />AdditionalDetails <br />Do you require a Purchase Order Number on the invoice? <br />If yes, please provide the PO# or forward a copy (front $ back) for our file. <br />Is a new purchase order required for each new fiscal period? <br />If yes, provide monthlyear PO expires: <br />Do you have multiple contracts, and would like them all billed on one invoice (Summary Billing)? <br />If yes, please provide your contract number: <br />Are you tax exempt? <br />If yes, please forward a copy of exempt certificate or direct pay permit. <br />Do you require ourW9 to establish us as a vendor? <br />Are there any additional billing requirements to ensure timely payments? <br />ZIP <br />711— Yes p No <br />Yes ❑ No <br />❑ Yes -,P9 No <br />Y, Yes ❑ No <br />"A Yes ❑ No <br />Payment Information <br />o Please check this boz if you ;ale Interested inenrolling in AutoPay. - <br />For other forms of payment, please note the. following remittance address (it may differ foam address for service and <br />supplies). Please include remittance slip with payment and send to: PO BOX 825736, PHILADELPHIA, PA 19182-5736 <br />This form completed by: Name: -a.'ie �bQn�lo Title: ASS}: �jn&,(JltetV Date: 2-02 <br />Page 1 of 1 <br />23ANC054V2 <br />433 <br />