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Attachment C <br />(Coun.t7Xity <br />%Fibnl) Jail. <br />(Street Address) <br />(Address.) (Phone n..t.un.b.er) <br />it Bed Reimbursement Fort <br />Medical Reimbursement Fnrm <br />an <br />Me <br />- <br />Doe, Jane <br />123456 <br />01/15/89 7/19/2015 7/21/2015 2 <br />$130,00 <br />smith, Johan y <br />121212 <br />02/26/62 7/8/2015 7/20/2015 12 <br />$780.00 <br />=17777711 <br />jahnsen, Doe <br />1/15 1 <br />-$65.00 <br />TOTAL <br />13 <br />$845,00 <br />Medical Reimbursement Fnrm <br />State of Washington K9561 (4) Page 25 of 25 <br />Department of Corrections 158362 <br />% <br />Oae,Jane <br />(23956 <br />1115p939 <br />5 <br />GabapomMUCTab <br />3 pilb <br />1234561 <br />Ilaw <br />7/20RO, <br />Tammy <br />y <br />y <br />$ 1.00 <br />12.50 <br />S 11.50 <br />I'llud <br />12:39in <br />Williams <br />uw525000p <br />NIA, <br />. Y,. <br />b : <br />S 1,56000. <br />. <br />S55555 <br />1013t) <br />1 <br />MillawallpailolGelleral <br />5 sveekq <br />Folely Object <br />Billi4:10 <br />NIP015, <br />Sauh <br />NIA <br />I <br />pendlag <br />$ 4.00 <br />$ 3,000.00 <br />$ 4,996.00 <br />Hos <br />R01116vol <br />C't"e , <br />State of Washington K9561 (4) Page 25 of 25 <br />Department of Corrections 158362 <br />