EFTA00181809

# Court-Ordered Payment System

INPUT FORM

FOR OP02 1 INITIAL ENTRY OF PAYEE



<table border="1"><tr><td>PAYEE TYPE CODE</td><td>PAYEE NAME*</td><td>PAYEE ADDRESS*</td><td>CONTACT PERSON/PHONE NUMBER</td><td>PAYEE ID# IF KNOWN</td><td>OFFCR.INIT</td><td>SUPV.INIT</td><td>DATA ENTRY INITIAL DATE</td></tr><tr><td>33</td><td>Drug Testing Training Trust Fund</td><td></td><td></td><td>33DCDRG000</td><td>GA</td><td></td><td>HS7120109</td></tr><tr><td>33</td><td>P.B. City Clerk</td><td></td><td></td><td>33DETRN001</td><td>GA</td><td></td><td></td></tr><tr><td>10</td><td>P.B. City Clerk</td><td></td><td></td><td>10COUNT050</td><td>GA</td><td></td><td></td></tr><tr><td>10</td><td>P.B. City Clerk(P.D. Fee)</td><td></td><td></td><td>10COUNT050</td><td>GA</td><td></td><td></td></tr><tr><td>25</td><td></td><td></td><td></td><td>25COUNT250</td><td></td><td></td><td></td></tr></table>

<table border="1"><tr><td>PFX*50</td><td>SEQ*2008</td><td>CNTYCODECF009</td><td>CASE#381AXXXMB</td><td>ACCTTYPE*</td><td>ORIGINALOBLIGATION</td><td>MONTHLYPAYMENTSCHEDULE</td><td>FINALPAYDUEDATE</td><td>CLAIM#POLICY#ATTENTION</td><td>S/D/H/PAYEEACCOUNT?</td><td>CMNTCODE</td></tr><tr><td>01</td><td>001</td><td>50</td><td>08-09381</td><td>09</td><td>65.</td><td></td><td></td><td></td><td>S</td><td>500</td></tr><tr><td>01</td><td>001</td><td>50</td><td>08-09381</td><td>24</td><td>24.</td><td></td><td></td><td></td><td>D</td><td>500</td></tr><tr><td>01</td><td>001</td><td>50</td><td>08-09381</td><td>03</td><td>473.</td><td></td><td></td><td>CF-AMB</td><td>S</td><td>500</td></tr><tr><td>01</td><td>002</td><td>50</td><td>08-09381</td><td>03</td><td>473.</td><td></td><td></td><td>FOR06-9454</td><td>S</td><td>500</td></tr><tr><td></td><td>001</td><td>50</td><td></td><td>26</td><td></td><td></td><td></td><td>CFMB/Dee</td><td>S</td><td>500</td></tr></table>

<table border="1"><tr><td>T RATE
F DATE / /</td><td>COS
ADM</td><td>INIT RATE</td><td colspan="2">OR
Supv Length End Date</td><td>Reason</td><td>OFCR INIT/
DATE / /</td><td>SUPV INIT/
DATE / /</td><td>DATA ENTRY
INIT.
DATE / /</td></tr><tr><td>T RATE
F DATE / /</td><td>EM</td><td>INIT RATE</td><td colspan="2">OR
Supv Length End Date</td><td>Reason</td><td>OFCR INIT/
DATE / /</td><td>SUPV INIT/
DATE / /</td><td>DATA ENTRY
INIT.
DATE / /</td></tr><tr><td colspan="9">FOR OP24 2 INITIAL ENTRY OF PRC SUBSTENCE DAILY RATE</td></tr></table>

<table border="1"><tr><td>T RATE</td><td rowspan="2">RATE $6.00</td><td rowspan="2">PRC Length=364 Days-OR</td><td rowspan="2"></td><td rowspan="2">Reason</td><td rowspan="2">OFCR INIT/DATE_/_/ _</td><td rowspan="2">SUPV INIT/DATE_/_/ _</td><td rowspan="2">DATA ENTRYIN/DATE_/_/ _</td></tr><tr><td>F DATE_/_/ _</td></tr></table>