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<br />EXAMPLE (See instructions on
<br />reverse side)
<br />
<br />TEXAS DEPARTMENT OF HEA~TH
<br />
<br />REQUEST FOR ABl.,'AUeC
<br />~ REIMBURSEMENT
<br />
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<br />TD1f":BD~n "6r1:l'BENTAL HEALTH
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<br />on ~___
<br />C0658723 N A
<br />L _ caw'lJrU) n TKIt . Sf
<br />1__ -' '___1
<br />(See Instructions for Dates)
<br />
<br />1742535353400
<br />i.litCii'c.. ~" ..
<br />
<br />
<br />.,:-.iCJ;.,uor, .oc .., "_MIl
<br />OA 1011I '''''100 ......NIl
<br />
<br />N/A
<br />
<br />
<br />......... N..... .116...... ~....,.
<br />
<br />,.._ CiFY of Jacksonville
<br />P.O. Box 111
<br />,,_ Jacksonville, IX 77777
<br />.....~~
<br />
<br />Ii_.
<br />
<br />N/A
<br />
<br />-....
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<br />_ alr CooIo
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<br />II. COWNTATIOfI Of AWOUrcT OF UJaleu_tKn/&DOlCU IlUlUUTUl
<br /> (~LUORI- (~I c.)
<br />PttOGIlANSlF1lINC:TIOHS/A.C:TIYIT1U .. DATION N/A N/A 1UT~
<br />.. T...,,",,_ (A. ./ ."1 4,680'
<br /> lIOIlIaon to _ See Instr. $ 4,680 $ $ $
<br />II. lA..: Cum..... pnIlInJim income ~:~: ~:~:~:~:~: ;:~:~: ~: ~ :~:;: ~:~ :~:WWlr~ ~m~~l1~l~l~ ~ ~~~~~~~~:~:~:~~~:~~;~~~;~~~~~:~~
<br />c. ~ Pf'O..... ....\IyI CLi.. . ...;...., 4,680 4,680
<br /> Ii.. u ..w..............w..
<br />... =locI_O.. oulUt}'S lor adotatIC. :~: ~:~: ~:~:~ :~:~:~:~:~: ~:~: ~:~: :~:~:~:~:~:~:~:~:~:~~:~:~:~:~:~
<br />:=:=:: :=:::: :::::::::::::::::::~ ::: :::=:=:::::: ::::::: ::::::::=:
<br />L T...I ISM" of...... It Itl 4 .680 4680
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<br />I. F_,oll"'''' eI 0_"1 .... h... . 4 ,680 4,680
<br />"- ,....,., ~.,__..nted _n_
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<br />..." IIIQIIaf
<br />_vtn'III
<br />2-20-91
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<br />_ _"" _ated.
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<br />x
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<br />I nu.......C
<br />
<br />Robert Lee Nichols, Mayor
<br />
<br />..._ c..lo
<br />I 512
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<br />.-.... .-..-
<br />, 555-21211
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<br />n.. _ fat o,...:y ....
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<br />C'-CUl".' NO ...ICJ ...0.110
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