&f5Y
&l2a0l0o6d1e65F
*p25y0X*c2400a3b0P
*p50y180X*c1050a3b0P
*p50y180X*c1050a50b30g2P
*p100y180X*c1050a3b0P
*p375y180X*c1050a3b0P

*p450y180X*c1050a3b0P
*p450y180X*c1050a50b30g2P
*p500y180X*c1050a3b0P
*p775y180X*c1050a3b0P

*p225y1860X*c450a3b0P
*p225y1860X*c450a50b30g2P
*p275y1860X*c450a3b0P
*p350y1860X*c450a3b0P

*p375y1860X*c450a3b0P
*p375y1860X*c450a50b30g2P
*p425y1860X*c450a3b0P
*p525y1860X*c450a3b0P

*p575y1860X*c450a3b0P
*p575y1860X*c450a50b30g2P
*p625y1860X*c450a3b0P
*p700y1860X*c450a3b0P

*p575y1320X*c450a3b0P
*p575y1320X*c450a50b30g2P
*p625y1320X*c450a3b0P
*p700y1320X*c450a3b0P

*p725y1320X*c450a3b0P
*p725y1320X*c450a50b30g2P
*p775y1320X*c450a3b0P
*p850y1320X*c450a3b0P


*p725y1860X*c450a3b0P
*p725y1860X*c450a50b30g2P
*p775y1860X*c450a3b0P
*p850y1860X*c450a3b0P

*p50y180X*c325b3a0P
*p450y180X*c325b3a0P
*p50y1230X*c325b3a0P
*p450y1230X*c325b3a0P

*p225y1860X*c125b3a0P
*p375y1860X*c150b3a0P
*p575y1860X*c125b3a0P
*p725y1860X*c125b3a0P
*p575y1320X*c125b3a0P
*p725y1320X*c125b3a0P


*p225y2310X*c125b3a0P
*p375y2310X*c150b3a0P
*p575y2310X*c125b3a0P
*p725y2310X*c125b3a0P
*p575y1770X*c125b3a0P
*p725y1770X*c125b3a0P

*p950y0X*c2400a3b0P
*p25y0X*c925b3a0P
*p25y2395X*c925b3a0P

*p1025y0X*c2400a3b0P
*p1050y180X*c1050a3b0P
*p1050y180X*c1050a50b30g2P
*p1100y180X*c1050a3b0P
*p1350y180X*c1050a3b0P

*p1050y1860X*c450a3b0P
*p1050y1860X*c450a50b30g2P
*p1100y1860X*c450a3b0P
*p1175y1860X*c450a3b0P

*p1225y1860X*c450a3b0P
*p1225y1860X*c450a50b30g2P
*p1275y1860X*c450a3b0P
*p1350y1860X*c450a3b0P

*p1375y0X*c2400a3b0P
*p1375y0X*c2400a50b30g2P
*p1425y0X*c2400a3b0P

*p1050y180X*c300b3a0P
*p1050y1230X*c300b3a0P
*p1050y1860X*c125b3a0P
*p1050y2310X*c125b3a0P
*p1225y1860X*c125b3a0P
*p1225y2310X*c125b3a0P

*p2550y0X*c2400a3b0P
*p2550y0X*c2400a75b30g2P
*p2625y0X*c2400a3b0P
*p2775y0X*c2400a3b0P
*p3125y0X*c2400a3b0P

*p1025y0X*c2100b3a0P
*p1375y180X*c1175b3a0P
*p1375y600X*c1175b3a0P
*p1375y690X*c1175b3a0P
*p1375y1530X*c1400b3a0P
*p1375y1830X*c1400b3a0P
*p1375y2130X*c1400b3a0P

*p1025y2395X*c2100b3a0P

*p2550y330X*c225b3a0P
*p2550y630X*c225b3a0P
*p2550y930X*c225b3a0P
*p2550y1230X*c225b3a0P

*p90y550XRemit To:
*p490y370XResponsible Party Name
*p265y1905XClosing Date
*p415y1875XAccount Number
*p615y1440XDue Date          Balance
*p765y1402XAmount Due
*p765y1862XAmount Enclosed

*p1090y630XFrom
*p1090y1905XClosing Date
*p1265y1875XAccount Number
*p1415y30XDate  Patient Name
*p1415y615XDr         Description          Charges  Payments  Balance

*p2600y945X0-30 Days
*p2600y1230X31-60 Days
*p2600y1535X61-90 Days
*p2600y1855X>90 Days  Amt Due

*p2585y45XPrevious
*p2585y375XCurrent
*p2585y675XFinance
*p2620y60XBalance
*p2620y360XActivity
*p2620y685XCharge

*p115y1450XSTATEMENT

(s16.66h12v0b3T
*p275y1450XCHARGES OR PAYMENTS
*p305y1450XMADE AFTER CLOSING
*p335y1450XDATE WILL APPEAR ON
*p365y1450XNEXT STATEMENT
*p945y900XDETACH THIS STUB AND RETURN WITH PAYMENT
*p995y0X-------------------------------------------------------- CUT ALONG THIS LINE -------------------------------------------------------------

*p3160y1790XForm GF-ST3 Dental Plan Inc. 6/93
*p135y0X
(s10h6v0b3T
&f5X
&f5y10X
&f5y4X
