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Laser Checks • One-Write Compatible Checks 3-Per-Page Checks • Deposit Tickets • Business Envelopes Manual Carbonless Business Forms

207.892.1850

Voucher Style (LV1) *Top, middle or bottom formats *1, 2 or 3 part available 8½” x 11” Single sheet 1 Check per sheet We have hundreds of check templates to match your software title and version. If you do not see it here, we can produce what you need, by supplying us with your sample via fax or email.

Laser/Inkjet Pantograph & Color Choices *Not all colors shown below are available for all checks. Please see chart on next page for availability.

207.892.1850

* 100% compatible guarantee with your customer’s software program. * LGP offers the most extensive standard pantograph and color selection available for basic imprint laser checks. * Digitally printed for increase accuracy and quality . * Shrinkwrapped for protection. * 100% compatible guarantee with your customer’s software program. * LGP offers the most extensive standard pantograph and c lor selection avail ble for basic imprint laser checks. * Digitally printed for increase accuracy and quality . * Shrinkwrapped for protection. Peachtree and hundreds of other titles.

(207) 655-9668 (207) 655-9668

CLASSIC with screened vouchers only CLASSIC with screened vouchers only

THEFACEOFTHISDOCUMENTHASACOLOREDBACKGROUNDONWHITEPAPERANDORIGINALDOCUMENTSECURITYSCREENONBACKWITHPADLOCKSECURITYICON.

PAYTOTHE ORDEROF PAYTOTHE ORDEROF

$ $

DOLLARS

MEMO 3 Per Page (LC3) *No payment stub eliminates waste 8½” x 3½” check 8½” x 11” sheet 3 Checks per sheet Wallet (LW3) PAYTOTHE ORDEROF PAYTOTHE ORDEROF DOLLARS MEMO DOLLARS

MEMO

ORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCU AUTHORIZEDSIGNATURE AUTHORIZE SIGNATURE

MEMO

STONE panto prints screen of black remaining prints in color, with white vouchers only THEFACEOFTHISDOCUMENTHASACOLOREDBACKGROUNDONWHITEPAPERANDORIGINALDOCUMENTSECURITYSCREENONBACKWITHPADLOCKSECURITYICON. STONE panto prints screen of black remaining prints in color, with white vouchers only

MARBLE-SKY with MICR white band & white vouchers only MARBLE-SKY with MICR white band & white vouchers only THEFACEOFTHISDOCUMENTHASACOLOREDBACKGROUNDONWHITEPAPERANDORIGINALDOCUMENTSECURITYSCREENONBACKWITHPADLOCKSECURITYICON. THEFACEOFTHISDOCUMENTHASACOLOREDBACKGROUNDONWHITEPAPERANDORIGINALDOCUMENTSECURITYSCREENONBACKWITHPADLOCKSECURITYICON.

THEFACEOFTHISDOCUMENTHASACOLOREDBACKGROUNDONWHITEPAPERANDORIGINALDOCUMENTSECURITYSCREENONBACKWITHPADLOCKSECURITYICON.

PAYTOTHE ORDEROF PAYTOTHE ORDEROF

DOLLARS

MEMO

AUTHORIZEDSIGNATURE

MEMO

AUTHORIZEDSIGNATURE

All Marble-Sky pantographs have a thermochromic heat sensitive image.

AMERICAN FLAG prints in red and blue with white vouchers only AMERICAN FLAG prints in red and blue with white vouchers only

LINEN with VOID feature and screened vouchers only LINEN with VOID feature and screened vouchers only

THEFACEOFTHISDOCUMENTHASACOLOREDBACKGROUNDONWHITEPAPERANDORIGINALDOCUMENTSECURITYSCREENONBACKWITHPADLOCKSECURITYICON.

MEMO *Includes stub for permanent record 6” x 2 11 / 16 ” check 8½” x 11” sheet 3 Checks per sheet Check Combinations Available PAYTOTHE ORDEROF PAYTOTHE ORDEROF skcehC detnirpmI - IVL Top w/Lines Top w/Sig Line Mid w/Sig Line Bottom No Lines skcehC detnirpmI - IVL Top w/Lines Top w/Sig Line Mid w/Sig Line Bottom No Lines w/Lines w/Lines No Lines No Lines DOLLARS $ $ ORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCU AUTHORIZEDSIGNATURE AUTHORIZE SIGNATURE MEMO DOLLARS $ $ ORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCUMENTORIGINALDOCU AUTHORIZEDSIGNATURE AUTHORIZE SIGNATURE

THEFACEOFTHISDOCUMENTHASACOLOREDBACKGROUNDONWHITEPAPERANDORIGINALDOCUMENTSECURITYSCREENONBACKWITHPADLOCKSECURITYICON.

PAYTOTHE ORDEROF PAYTOTHE ORDEROF

DOLLARS

MEMO

AUTHORIZEDSIGNATURE

MEMO

AUTHORIZEDSIGNATURE

skcehC detnirpmI - 3CL skcehC detnirpmI - 3CL w/Lines

skcehc detnirpmI - 3WL skcehc detnirpmI - 3WL

AVAILABILITY AVAILABILITY

w/Sig Line Only w/Sig Lin Only

w/Lines

CLASSIC Blue CLASSIC Blue

X X X X X X X X X X X X X X X X X X X X X X X X X

X X X X

X X X X X X X X X X X X X X X X X X X X

X X X X

Green Gre n Burgundy Burgundy P ple Yellow Brown Gray Purple Yellow Brown Gray

STONE Blue STONE Blue

X X X X X X X X X X X X X

Green Gre n Burgundy MARBLE-SKY Blue Burgundy MARBLE-SKY Blue

Green Gre n Burgundy P ple Teal Burgundy Purple

Teal LINEN LINEN Blue

Blue Green Gre n Burgundy Tan SPECIALTY Burgundy Tan SPECIALTY

X X

American Flag American Flag

mainelabel.com

MCD Manual Cash Disbursement Check with record. MPR Manual Payroll/Cash Disbursement Check - employee & business record. MCD & MPR Specifications 8¼” x 3” Check w/Ticket 9” x 12 7 / 8 ” Sheet 3 Checks per sheet *7-Ring Binders Available. TCC Travel Convenience Check. Perfect for those who need a business size check on the go. TCC Style/Color Options Bordeaux - Burgundy Executive - Blue

MCD Style/Color Options Executive - Blue Parchment - Yellow Tranquility - Green Marble Sky - Blue, Green, Purple, Teal, Yellow & Green

MPR Style/Color Options Bordeaux - Burgundy Executive - Blue

Parchment - Yellow Tranquility - Green

Security Features Protect our checks from fraud. Our checks are manufactured with special security features that make copying or altering easy to detect! Our checks exceed the standard set forth by the Check Payment system Association guidelines. We are licensed to use the security certification icon (“Padlock Icon”) on all our negotiable documents. Even though the CPSA calls for two standard security features on each check, we offer many more at no additional cost.

B. Security Pantographs Our custom check backgrounds are designed to limit reproducibility by scanning or photocopying, while also ensuring check readability. C. Padlock Icon This security symbol warns that the check is security protected and is found on both sides of the check, with a description of at least two of the security features on the back of the check to verify authenticity. D. “MP” Logo MP, which stands for MicroPrinting, is recommended by the Check Payment Systems Association (CPSA) and is used on all our checks.

E. MicroPrinted Signature Lines On each signature line of our checks, we print microscopic lettering in type that is too small to be reproduced by scanning or photocopying that reads “ORIGINAL DOCUMENT”. A. Warning Band Found in the border of the check this warning band indicates the security features of the check for easy identification. Not available in all manual check styles. F. Security Screen A security screen that reads “ORIGINAL DOCUMENT SCREEN” is found on the back of all our checks, listing all security features included on the check. This screen is unable to be photocopied clearly.

O R I G I N A L D O C U M E N T O R I G I N A L D O C U M E N G I N A L D O C U M E N T O R I G I N A L D O C U M E N T O R I G I N A L D O C U M E N T O R I G I N A L D O C U M E N T O R I G I N A L D O C U M E N T O R I G I N A L D O C U M E N T O R I G I N A L D O C U M E N T O R I G I N A L D O C U M E N T O R I G I N A L D O C U M E N T O R I G I N A L D O C U M E N T O R I G I N A L D O C U M E N T O R I G I N A L D O C U M E N T O R I G I N A L D O C U M E N T O R I G I N A L D O C U M E N T O R I G I N A L D O C U M E N T O R I G I N A L D O C U M E N T O R I G I N A L D O I G I N A L D O C U M E N T O R I G I N A L D O C U M Warning: DONOTWRITE,STAMPORSIGNBELOWTHISLINE RESERVED FOR FINANCIALINSTITUTIONUSE*

•Tiny type on front and back of document fills in to form solid lineswhen scanned or photocopied.

•Copy resistant security pantograph on front of document discourages clear duplication.

•Warns receivers to be aware of detailed security features. • “OriginalDocument” text, andweave apttern visible on back of check,will not appear if scanned or photocopied.

•Prevents chemical “lifting” and alteration of imprint information.

Padlock design is a certificationmark of theCheck PaymentSystemsAssociation

*FEDERALRESERVEBOARDOFGOVERNORSREG.CC

MPMicroprint Absenseof the followingSecurityFeaturesmay indicatealteration SecurityPantograph WarningBands/MPPadlock Logos SecurityScreenBacker OffsetPenetrating Ink Imprint

ENDORSEHERE

207.892.1850

Nebs ® or McBee ®

Deluxe ® or Safeguard ®

Standard McBee holes

Standard Safeguard holes

St n ard McBee holes

St n ard Safeguard holes

One-Write Pantograph Colors

Deluxe ® or Safeguard ®

Nebs ® or McBee ®

blue, gray, green, gold & rose

blue, green, rose & gold

Pegboards Available McBee Style: Navy Blue, Black, Brown

Safeguard Style: Navy Blue, Black, Brown, Green

Journals: Available for some One-Write checks in packages of 50 or 100 Pegboard - One write system checks Compatible with all Deluxe ® , Nebs ® , McBee ® & Safeguard ® round hole formats. Duplicate checks available.

mainelabel.com

Multipart Deposit Slips: Printed with Account Number, Name & Address.

Personal Deposit (PDT) Indicate number of parts when ordering Size: 6¼” x 3 1 / 8 ”

BDT

D30

Order# DistributorBug

D25

Order# DistributorBug

D E P O S I T T I C K E T PLEASE BE SURE ALL ITEMS ARE PROPERLY ENDORSED. LIST EACH CHECK SEPARATELY Checks and other items received for deposit subject to the terms and conditions of this bank’s collection agreement. Deposits may not be available for immediate withdrawal.

D E P O S I T T I C K E T

BANK NAME BANKADDRESS1 BANKADDRESS2 ROUTING/TRANSIT

DATE

DOLLARS CENTS

DATE

DOLLARS

CENTS

. . . . . . .

CASH

DEPOS IT T ICKET

DOLLARS

CENTS

CURRENCY

ROUTING TRANSIT

CURRENCY COIN CHECKS COMPANY NAME LISTEACH SEPARATELY

BANK NAME BANK ADDRESS 1 BANK ADDRESS 2

x 100 x 50 x 20 x 10 x 5 x 2 x 1

COIN CHECKS LIST SEPARATELY

COMPANY NAME

CASH CHECKS

1 2 3 4 5 6 7 8 9

ADDRESS 2

ADDRESS 3

ADDRESS 1

PHONE #

1 2 3 4 5 6 7 8 9

ADDRESS 3

ADDRESS 2

ADDRESS 1

PHONE #

20 DEPOSITSMAYNOTBEAVAILABLEFOR IMMEDIATEWITHDRAWAL

DATE

COMPANY NAME

SUB TOTAL

ADDRESS 1

ADDRESS 3

ADDRESS 2

PHONE #

SIGNHEREONLY IFCASHRECEIVEDFROMDEPOSIT

LESSCASHRECEIVED

COMPANY NAME ADDRESS 1 ADDRESS 3 PHONE # ADDRESS 2

$ . COIN

Checksandother items received fordepositsubject to the termsandconditionsof thisbank’scollectionagreement. DistributorBug

PDT

Order #

TOTALCASH

10 11

TOTAL

ITEMS

CHECKS 1 2 3 4 5 6 7 8 9

TOTAL

ITEMS

13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

10 11 12 13 14 15 16 17 $ . PreparedBy VerifiedBy PLEASE RE-ENTER TOTALHERE

TOTAL

ITEMS

TOTAL DEPOSIT

ROUTING/TRANSIT

BANK NAME

TOTAL

PLEASE RE-ENTER TOTALHERE

TOTAL

All manual deposit slips assembled in books, except 3 & 4 Part loose sets.

CHECKSANDOTHER ITEMSARERECEIVEDFOR DEPOSITSUBJECTTOTHEPROVISIONSOFTHE UNIFORMCOMMERCIALCODEANDANY APPLICABLECOLLECTIONAGREEMENT.

CHECKS AND OTHER ITEMS ARE RECEIVED FOR DEPOSIT SUBJECT TO THE PROVISIONS OF THE UNIFORM COMMERCIAL CODE AND ANY APPLICA- BLECOLLECTIONAGREEMENT.

VerifiedBy Bag # PreparedBy

Please Print

TOTAL PLEASEENTERTOTALHERE

PleasePrint

D30 17 Deposit entries. Indicate number of parts when ordering Size: 8¾” x 3¾”

D25 Cash breakdown & 9 Deposit entries. Indicate number of parts when ordering Size: 8¾” x 3¾”

Standard BDT 32 Deposit entries. Indicate number of parts when ordering Size: 8¾” x 3¾”

QBDT For use with Quickbooks ® or later.

CASH

DEPOSIT TICKET

Date

Computer Printable Deposit Slips Indicate number of

SUBTOTAL LESS CASH RECEIVED

Signature

SIGNHERE FOR LESSCASH

DATE:

TOTAL NUMBEROF DEPOSITED ITEMS

DEPOSITMAYNOT BE AVAILABLE FOR IMMEDIATEWITHDRAWAL ALL ITEMSRECEIVED FORDEPOSIT ARE SUBJECT TO THE RULES ANDREGULATIONSOF THE FINANCIAL INSTITUTION

deposit ticket

CASH:

CHECKS:

OTHER:

TOTALITEMS:

DATE:

TOTALDEPOSIT:

parts (1, 2 or 3) when ordering. Size: 8½” x 3½” slips 8½” x 11”sheet 1 slip per sheet

DEPOSITDETAIL

PTDT For use with Peachtree ® .

IMPORTANT:Both parts of this formmust be submitted to your bankwhenmaking a deposit. Printed inU.S.A.

207.892.1850

Double Wi Use with Invoic Now availab As 5022SS with S

9308 8 7 / 8 x 4 1 / 8

1”

PH: 1-888-440-IBBI (4224) FAX: 1-877-513-IBBI (4224) E-MAIL: dibbotson@ibbionline.com WEBSITE: www.ibbionline.com

3 / 8 ”

3 1 / 2 x 7 / 8 ”

7 / 8 ”

Double Window Envelope

Use with Now As 5022SS P

9308 8 7 / 8 x 4 1 / 8

1”

3 / 8 ”

PH: 1-888-440-IBBI (4224) FAX: 1-877-513-IBBI (4224) E-MAIL: dibbotson@ibbionline.com WEBSITE: www.ibbionline.com

4 x 1”

3 / 8 ” Double Window Check Envelopes Our business envelopes are provided blank as they are compatible with your checks, invoices and statements to allow addresses to show through windows. Choose regular (gummed) or self- sealing style. All of our business envelopes (excluding 9308-Regular) hav a security screen inside. Our standard double windows envelopes are displayed below. 3 1 / 2 x 7 / 8 ” 4 x 1” Use with Invoices and Statements Now available in Self-Seal As 5022SS with Security Screen inside 3 / 8 ” 3 / 8 ” 7 / 8 ” 1 / 2 ” 3 1 / 2 x 7 / 8 ” 9308 8 7 / 8 x 4 1 / 8 1” 1 / 2 ” 5 / 8 ” 9379 8 3 / 4 x 3 5 / 8 3 1 / 2 x 7 / 8 ”

Use with Quickbooks/ Available in Reg

3 / 8 ”

3 / 4 ”

PLEASE CALL FOR PRICING

7 / 8 ”

5 / 8 ”

9308 8 7 / 8 x 4 1 / 8

3 / 8 ”

Use with Quic Available P

1”

9379 8 3 / 4 x 3 5 / 8

3 3 / 4 x 13 / 16 ”

3 / 8 ”

5 / 8 ”

4 x 1”

13 / 16 ”

3 1 / 2 x 7 / 8 ”

3 / 8 ”

1 / 2 ”

3 1 / 2 x 7 / 8 ”

3 / 4 ”

7 / 8 ”

5 / 8 ”

3 / 8 ”

Use with Peacht Available in Reg

DW-84 8 3 / 4 x 3 2 / 3

3 / 8 ”

13 / 16 ” Use with Quickbooks/Quicken LV1 and LC3 Available in Regular and Self-Seal 1 / 2 ” 3 3 / 4 x 13 / 16 ”

9379 8 3 / 4 x 3 5 / 8

3 / 8 ”

5 / 8 ”

3 7 / 8 x 1”

4 x 1”

3 1 / 2 x 7 / 8 ”

1 / 2 ”

3 / 4 ”

PLEASE CALL FOR PRICING

5 / 8 ” 9308 (Regular) & 5022 (Self-Seal) For use with invoices & statements. 9308 does not include a security screen. 13 / 16 ” 3 3 / 4 x 13 / 16 ”

1 / 2 ” 9379 (Regular) & 9379-SS (Self-Seal) For use with Quickbooks ® & Quicken ® LV1 & LC3. 3 / 8 ” 3 7 / 8 x 1” 5 / 8 ” 4 x 1”

5 / 8 ”

Use with Available P

DW-84 8 3 / 4 x 3 2 / 3

3 / 4 ”

5 / 8 ”

3 / 8 ”

#1 Not availabl

4 x 1” Use with Peachtree and Most LV1 Available in Regular and Self-Seal 13 / 16 ”

WALLET 6 1 / 4 x 3 1 / 2 ”

DW-84 8 3 / 4 x 3 2 / 3

1 / 2 ”

7 / 8 ”

5 / 8 ”

3 7 / 8 x 1”

2 5 / 16 x 5 / 8 ”

1 / 2 ”

3 / 4 ”

PLEASE CALL FOR PRICING ”

5 / 8 ”

3 / 8

WALLET 6 1 / 4 x 3 1 / 2 ”

13 / 16 ”

3 1 / 8 x 7 / 8 ”

Not a P

4 x 1”

7 / 8 ”

3 / 4 ”

2 5 / 16 x 5 / 8 ”

5 / 8 ”

1 / 2 ”

SEL-DWE-07

3 / 8 13071 (Regular) For use with Wallet LW3 Checks. Not available in Self-Seal ” 3 / 4 ” 3 1 / 8 x 7 / 8 ”

WALLET 6 1 / 4 x 3 1 / 2 ” DW-84 (Regular) & DW-84-SS (Self-Seal) For use with Peachtree ® and most LV1. 13 / 16 ”

#13071 Not available in Self-Seal

7 / 8 ”

2 5 / 16 x 5 / 8 ”

SEL-DWE-07

1 / 2 ”

PLEASE CALL FOR PRICING

We also offer a wide variety of other types of envelopes in a variety of sizes, with 1-Color, Spot Color & 4 Color printing available. Call us today for all of your envelope needs!

”

3 / 8

3 1 / 8 x 7 / 8 ”

3 / 4 ”

SEL-DWE-07

mainelabel.com

Our variety of manual forms come Edge Clued or Snap-a-part with 2-5 parts. 1 or 2 sided printing is also available. Standard 20# Carbonless • Standard Color Sequence (2-4 Parts) White, Canary, Pink & Gold • Standard Color Sequence (5 Parts) White, green, Canary, Pink & Gold • Standard Ink Colors Black, Reflex Blue, 347 Green, 208 Burgundy, 032 Red & 185 Red (All other Pantone colors available at additional cost) • Additional Services Available - Wrap Around Covers - 1, 2, 3 & 4 spot color printing - Padding, Drilling & Numbering

COPIES #

1a. FIRSTNAME

1b. MIDDLENAME

1c. LASTNAME

1d. JR.,etc.

2. DATEOFDEATH (Mo,Dy, yr)

3. SEX 4. SOCIALSECURITYNUMBER 5a. AGE (Yrs) 5b. UNDER1YEAR 5c. UNDER 1DAY 6. DATEOFBIRTH (Mo,Dy,Yr) Months Days Hours Minutes

LastBirthday

7. BIRTHPLACE (City andState orForeignCountry)

8. WASDECEDENT 9.PLACEOFDEATH (Check onlyone) EVER INU.S. YES HOSPITAL: DOA

OTHER:

NursingHome Residence

ARMEDFORCES? NO Inpatient ER/Outpatient Other (Specify)

HobbsSouthPortland

10. FACILITYNAME (If not institution,give street andnumber)

11.COUNTYOFDEATH 12. CITYORTOWNOFDEATH

13. MARITALSTATUS 14. MOSTRECENTSPOUCE (Ifwife,

15. DECEDENT’SUSUALOCCUPATION (Give kind ofwork 16. KINDOFBUSINESS / INDUSTRY FUNERAL ARRANGEMENTS doneduringmost ofworking life. Donot use retired.) 19. RACE -American Indian,Black,White,etc. (Specify)

DECEDENT PARENTS INFORMANT FATHER’S MOTHER’S

givemaiden name)

Married NeverMarried Living Deceased Widowed Divorced 17. DECEDENT’SEDUCATION (Specify onlyhighestgrade completed) 18. ANCESTRY -French,English, Irish,etc. (Specify)

Elementary/Secondary College (0 - 12grades) (1 - 4 or 5+ years) 20. RESIDENCESTATE 21. RESIDENCECOUNTY 22. RESIDENCECITYORTOWN

23. RESIDENCESTREETANDNUMBER

Name: DateofDeath:

24d. JR., etc. File #: MortuaryTrust ID: Amount:

24a. FIRSTNAME

24b. MIDDLENAME 24c. LASTNAME

Time:

25a. FIRSTNAME

25b. MIDDLENAME

25c. MAIDENSURNAME

PlaceofDeath:

26. INFORMANT -NAME (Type orPrint)

27. MAILINGADDRESS (Street andNumber orRuralRouteNumber,CityorTown, State, ZIPCode)

28. RELATION

29. T.O.D.

30. PHONE

¨ NO Director: Zip:

Residence:

31. METHODOFDISPOSITION: ¨ Temporary

¨ Burial

¨ Cremation

¨ Removal

¨ UsebyMedical

¨ Other (Specify)

32. WASBODYEMBALMED

Storage

FromState Science

¨ YES

33b. LOCATION (City,Town,State) City: State:

33a. PLACEOFDISPOSITION (Name ofCemetery,Crematory,orOtherPlace)

33c.DATEOFDISPOSTION (Mo.Dy.Yr.)

Informant:

Phone:

Biographical Information Name &Age Address:

Relationship:

City: State:

Zip:

Place of Birth:

Parents: Schooling:

Military: Service Details: Funeral Memorial Graveside Public Private None Visitation: Service: Reception: Burial: Date Day Time Place Date Day Time Place Date Day Time Place

Employment History:

Date

Day

Time

Place

ReligiousAffilation:

Church:

Arrangements

Disposition: Cremation Burial Tomb

Need

Done

Physician: Phone #: Fax #:

Clubs & Organizations: Hobbies: Predeceased by: Survivors: In Lieu of Flowers:

Church: Clergy: Casket: Open / Closed Vault: Urn: Flowers: Hairdresser: Organist: Sexton: Reg.Book: PrayerCards: Prayer:

EDRS File #: MERelease

Veterans Branch ofService:

Flag Honors

Marker Benefits

Obituary/Notice: Photo /NoPhoto Date toRun

Notice: Paper:

Reception Hostess: Caterer: FoodOrder:

WindhamFireRescueDepartment 375GrayRoad Windham,Maine 04062 Tele # (207) 892-1911 Fax # (207) 892-0544 FireAlarmDetection&SuppressionActivationReport

WindhamFire -RescueDepartment 375GrayRoad Windham,ME 04062 WindhamFire -Rescu Department 375GrayRoad Windham,ME 04062

Date:___________ Incident#_________BusinessNameorResidence:_________________________________ Address:_______________________________________________TimeofAlarm:________________________ ContactName:___________________________Title:________________Phone:_________________________ PersonWritingReport:____________________OccupancyUse:______________________________________

Location ________________________________ Time ofAlarm ___________________________ Questions to askOccupants: Are there anymembers of the household feeling ill? Headache YES NO Location Time ofAlarm

_____ _____

IncidentNumber _______________ Time ofMeasurement ___________ IcidentNumber Time ofMeasurement

_____ _____

Quesion to askOccupants: A there anymembers of th usehold feeing ill? Headache YES NO

HOUR GLASS (207) 775-9915 619MainStreet,SouthPortland,ME 04106

Fatigue

YES NO

IncidentComments.PleaseNoteAll Issues. Important Information forNewPatientsofCommunityDental 1. In ord r to best serve you as a patient ofCommunityDental please complete the attached paperwork and bring ormail it to the centerwhere you are seeking services. CommunityDentalBiddeford , 57BarraRd.,Suite 3,Biddeford,ME 04005 (207) 282-1305 CommunityDentalFarmington , 131FranklinCommons,Ste I ,Farmington,ME 04938 (207) 779-2659 CommunityDentalLewiston , 177MainSt., Lewiston,ME 04240 (207) 777-7442 CommunityDentalPortland , 640BrightonAve,Portland,ME 04102 (207) 874-1028 CommunityDentalRumford , 60 LowellSt,Rumford,ME 04276 (207) 369-3600 2. On the day of your appointment, please arrive 10minutesbefore your appointment time. It is required that you bring your insurance card with you to each appointment. 3. A parentorguardian must accompany patients under 18 years of age and remain at theCenter during the length of the appointment. 4. Payment for dental services is due at the same time you receive the dental care. There is a $25 fee for any check payments returned for non-payment. 5. If you are requesting consideration for our income based sliding fees , youmust complete the sliding fee application (on page 3) and include copies of all proof of household income.Thismay include: • A copyof yourmost recentTaxReturn,currenthouseholdW-2sorpay stub(s) that includes year todate income total. • A copyof yourTANFCheck,SSI/SSDICheck,RetirementCheck,VABenefitsorBank statementofDirectDeposit for anyof the above • Alimony, child supportpayment,CityorGeneralAssistanceVoucher Proof of incomemust be updated annually. Full feeswill be applied if documentation is not receivedwith application. ACCOUNT NO. AGENT NO. PURCHASE ORDERNO. CONTRACTOR LICENSE# STATESALESTAX# CUSTOMERSTATETAXOREXEMPTNO. CUSTOMERFEDERALTAX I.D.NO. SOURCE SALESMAN I.D. 10 INSURANCEPROOFOFLOSS VEHICLE INFORMATION SOLDTO: CUSTOMER: POLICYNO: CLAIMNO: CAUSE& LOSS LOCATION VERIFIEDBY DATEOFLOSS

Nausea

YES NO

Dizziness

YES NO

Situation foundupon arrival.Please check allboxes that apply. HumanElement.

Shortness ofBreath YES NO Other ____________________________________________________ YES NO A “YES” response to any of thequestions requires andEMS evaluationby theparamedic. Do you feel better away from the house? YES NO What applianceswere on at the time of activation? _________________________________ What applianceswere in use in the last 24 hours? __________________________________ GasDetectionMeterChecklist Area of RoomLocation PPMReading Area of RoomLocation Shortness ofBreath YES NO C fusion YES NO Other _____ YES NO A “YES” respnse t any of thequestions rquires andEMS evaluationby theparamedic. Do you fel betteraway from th house? YES NO What appliancswere onat the time of activation? _____ What appliancswer i us in the last 24 hours? _ _____ GasDetectionMetrChecklist Area of RomLocation PPMReading Area of RomLocation Dba:FreeRangeFish&Lobster Phone: (207)774–8469 Fax: (207) 774–8466 FREEDOMFISH,LLC 450CommercialStreet Portland,ME04101 StraightBillofLading DELIVERING CARRIER: TO: Consignee DATE YES NO Confusion

XXXXX

Dba:MaineStreamSeafood Phone: (207) 871–9020 Fax: (207) 871–5030

DATE

FireAlarm activation intentional FireAlarm activationunintentional FireAlarm activationunknown Sprinkleractivation intentional Sprinkleractivationunintentional Sprinkleractivationunknown FireAlarmorSprinklerSystem condition.

FEDERALTAX I.D.NO.

INSTALLEDBY

ORDERTAKENBY

27-2627546

PPMReading Received subject to the classifications and tariffs in effect on the date of the issue of thisBillofLading, thepropertyasdescribedhere inapparentgoodorder,except as noted (contents and conditions of contents of packages unknown), consigned, and destined as indicated here which said carrier (the word carrier being understood throughout this contract as meaning any person or corporation in possession of thepropertyunder the contract)agrees to carry to theusualplaceof delivery at saiddestination ifonhis route,otherwise todeliver toanother carrier on the route to said destination. It ismutually agreed as to each carrier of all or any of said property over all or any portion of said route to destination and as to each party at any time interested in all or any said property, that every service to be performed hereunder shall be subject to all the bill of lading terms and conditions in the governing classification on the date of shipment. Shipper hereby certifies that he is familiarwith all of the bill of lading terms and conditions in the governing classification and the said terms and conditions are hereby agreed to by the shipper and accepted for himself and his assigns. PPMReading

Street

OutsideReading

GasDryer

TOREORDERCALL: (207) 892-1850 • MAINE LABEL&PRINTING • POBOX 938,WINDHAM,ME 04062

Destination Ship to AWB

ZipCode

HotWater Heater

FireAlarm systempartially shutdown FireAlarm system completely shutdown FireAlarm left in“trouble” condition Sprinklerpartially shutdownor impaired Sprinkler completely shutdown DryPipeSystem tripped Dry sprinkler left inawet condition Have you verified that thepropertyownerormanagerhasbeennotifiedof theproblembefore you cleared the scene? Yes o No o HasFireAlarmbeennotified of the situation, and the informationhasbeen logged into the incident? Yes o No o HasFireAlarmSystembeen restored? Yes o No o INSURANCECO: INSURANCECO: PHONENO. POLICYNAME AGENTNAME AGENTPHONE NAME ODOMETER

XXXXX

Entry

SHIPPERORCONSIGNOR

CRATE INVOICE

TOTES

OrderBy

PackedBy

PortableHeater

Portabl Heater

Furnace

_____ 21GREATREPUBLICDRIVE GLOUCESTER,MA01930 (978) 330-3051 •FAX (978) 513-8426 CUSTOMERNAME LOCATION ofTRANSACTION DRIVER Price Lbs.

IN:

OUT:

Refrigerator

Chimney Fireplace Product

Chimney

DATE

No. Packages

Extended Price

Stove /Oven

Sto /Oven

Fireplace

Stove /Hood

Garage

CODetector

BBQGrill

DEDUCTIBLE

CODetector Information ____________________________________________________________________ Make ____________________________________ Model _____________________________ Name of Individual handling theCOmeter ______________________________________________________ Officer completing the checklist _______________________________________________________________ Received by ______________________________________________________ Date: ___________________ Homeowner orTenant This checklist shall be completed for allCarbonMonoxide detector activations. The completed sheet shall be completed and returned to the office. The owner or occupant shall be given part two of the sheet CODetect Infrmation Make _____ Model Name of Individua handling theCOmeter _ Officer completing the checklist Received by _____ Date: Homeowner orTenant This checklist shall be completed for allCarbonMonoxide detetor activations. The completd eet shall be completed and returnedt th office. Th owner or occupnt shall begiven part two of thesheet CRATES PALLETS BARRELS

_____

_____ CONTAINER TOGLOUCESTER

TOCUSTOMER

BALANCE

MODEL LICENSE

YEAR VEHICLE I.D.NO.

DOORS

_____

o No ImportantBrokenAppointmentNotice Missed appointments prevent patients from getting the care they need. Community Dentalmay restrict patients from scheduling appointments if they have broken an appointment. An appointment is considered to have been broken if: 1. The patient fails to appear for the appointment, or 2. The patient arrives too late for a scheduled appointment, or 3. The patient cancels an appointmentwith less than 24hoursnotice

Signature ofOccupancyOwnerorManager: ______________________________________________

VATS

January 2012

OfficeUseonly:FollowupRequired? Yes o FollowupDate: ______________F.D.Personwho followedup______________________________

WhiteCopy toOffice CanaryCopy toCustomer

OTHER

Quantity H.D.

H.A.

ORIGINALSHIPPER

TYPE

❏ PREPAID TOTAL ➤ WHITE -OFFICE CANARY -CUSTOMER PINK -CARRIER GREEN -CARRIER BLUE -CARRIER COMMENTS: ❏ COLLECT

FREIGHT:

www.facebook.com/communitydentalmaine WORKAUTHORIZATION Iherebyauthorize theabovework tobedone togetherwith thenecessarymaterial,but request that you contact me if the costof the service exceeds the amount reflected on the invoice. ASSIGNMENTOFPROCEEDSANDAUTHORIZATIONTOPAY: Replacement or repair of the glass inmy automobilehasbeen done tomy satisfaction. I authorizemy insurance company to release policy, coverage andother information toHourGlass. I hereby authorize anddirect my insurance company topay this invoicedirectly.HourGlass and I assign any and all claims in connectionwith this automobileglass installation or repair againstmy insurance company and all policyproceedsdue for this installation or repair toHourGlass. I agree that ifmy insurer should ignore thisdirective to pay and the assignmentof thepolicyproceeds and issue payment tome that Iwill immediately forwardpayment toHourGlassby either endorsing the check that I receiveover toHourGlassorpayingHourGlass an amount equal towhat I received. If I donothave insurance coverage. I agree topay forworkmyself. IMPORTANT WARRANTYTERMS ON BACK CUSTOMER’SSIGNATURE

WhiteCopy forpropertyowner Yellow&PinkCopy forFireDepartment

www.communitydentalme.org

CheckoutourWebsite

GLOUCESTERSEAFOODPROCESSING (PLEASEPRINTNAME)

TERMS

CUSTOMER (PLEASEPRINTNAME)

CUSTOMER’SSIGNATURE

TOTALSALE

TERMS:NET30DAYS,SERVICECHARGEOF 1 1/2%PERCENTPERMONTH (18%PERYEAR)WILLBECHARGEDONOVERDUEACCOUNTS TRANSACTION ISSUBJECTTOTERMSANDCONDITIONSONREVERSESIDE

207.892.1850

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