important: return a copy of this invoice with remittance invoice of fees for foia services *case number date material requested charge to name of requestor organization street address City zip code state number number reproduction each page 10 ¢ other (e.g. computer printout) search fees; Per hour (Based on Salary of Searcher as per 45 CFR 5.43) Level 1 Level 2 Level 3 review fees; Per hour (Based on Salary of Reviewer as per 45 CFR 5.43) Level 1 Level 2 Level 3 special services; certification ($10.00) return receipt ($2.15) other pay total of $ Questions regarding enclosed material or charges, call: make check or money order payable to: Centers for Medicare & Medicaid services and remit with a copy of this invoice to: Centers for Medicare & Medicaid services division of accounting P.O. box 7520 baltimore, md 21207-0520 *please include the case number on your check or money order Enclosed is payment of $ Form CMS-633 (01/08) by check money order SEE REVERSE SIDE American LegalNet, Inc. www.FormsWorkflow.com If payment is not made within 30 days of the date of this invoice, interest and administrative costs will be assessed and future requests for information will not be honored until payment is made. Your name and account information will be turned over to a private collection agency and credit bureau if your account becomes 60 days overdue and associated costs will be added to the account. Additional penalties of six percent will be assessed on accounts delinquent for more than 90 days and such accounts may be referred to the IRS or the Justice Department for judicial action. (The Debt Collection Act of 1982.) American LegalNet, Inc. www.FormsWorkflow.com