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Customer Name: <br />OBF Loan Number: <br />Site Service <br />Account <br />Number <br />OBF Billing <br />Repayment <br />Service Account <br />Number <br />1' Monthly <br />OBF Loan <br />Payment <br />Remaining Monthly <br />OBF Loan Payments <br />X -XXX- <br />XXXX -XX <br />X- XXX- XXXX -XX <br />$XX.XX <br />$XXX.XX per month for X months <br />Total Monthly Repayment <br />$XX.XX <br />$XXX.XX per month <br />for X months <br />Form 14 -792 <br />05/2012 <br />20B-43 <br />