Bill To:


STATE FARM INSURANCE
PO BOX 52250
PHOENIX, AZ 85072-2250

Services Rendered To:


Huzefay Ghor
4205 Highgrove Drive
Arlington, TX 76001
Policy # 338 0410-L01-53B 002

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-SH-214-C21-31072 12/15/2021 01/06/2022 On Receipt Richland Volunteer Fire Department

Product
Price
Qty
Amount
  1. 103 Rescue Response (Per Hour)

    $300.00
    1
    $300.00
  2. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  3. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: Interstate 45 Southbound @ 214 - Richland, Texas

    Ordinance Info: Richland Billing Ordinance NO. 170 Cost Recovery

Subtotal $550.00
Total Due $550.00


Updated
January 6, 2022 @ 6:01 pm

Invoice updated by Geoffrey.

Status Update
January 6, 2022 @ 6:01 pm

Status changed: Draft to Pending.