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Cause Number*
Name of Obligor/NCP*
Name of Obligee/CP*
I am the attorney of record for* a party in the above-referenced cause number.
State Disbursement Record*
or
Office of the Attorney General FINA Record*
Attorey's Printed Name*
Bar Number*
Phone Number*
Fax Number*
Office Address*
Attorney of Record Electronic Signature*
Date*
*I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
