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ENCY STATEMENT OF TRANSACTION FOR ACCOUNTING PERIOD ENDING Document No. CUSTOMER AGENCY Agency Location Code (ALC) Customer Agency Voucher No. BILLING AGENCY Agency Location Code (ALC) Billing Agency Voucher No. DEPARTMENT BUREAU ADDRESS DEPARTMENT BUREAU ADDRESS SUMMARY SUMMARY APPROPRIATION, FUND, OR RECEIPT SYMBOL ( MUST AGREE WITH BILLING AGENCY) AMOUNT TOTAL Details of charges or reference to attached supporting documents $0.00 APPROPRIATION, FUND, OR RECEIPT SYMBOL ( MUST AGRE.

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