Central Collection Unit 300 W. Preston ...

Central Collection Unit

300 W. Preston Street, Room 503

Baltimore, MD 21201

Telephone 410-767-7413

Fax: 410-333-5595

E Mail: rmation@

1. CCU Creditor Shortname

(To be completed by CCU)

2. Existing Creditor Shortname (if Applicable)

-

3. Taxpayer ID Number (if Applicable)

4. Creditor Name

5. Creditor Address

Street

City

State

-

6. Creditor Telephone Number

Zip Code

-

Fax Number

-

-

7. Creditor Contact Person

8. Contact E-Mail Address

9. Interest Bearing? Rate?

Y N

Rate

10. Appropriation Codes

Budget Code

Program

Fund

11. Fund Source

Source

(General, Federal, etc.)

R*STARS

Agency

PCA

TC Code

,

Comp/Agency Object

12. Form Completed By

Print and Sign Name

Date

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download