NAME DOE, JOHN                    HIC XXXXXXXXXX     ACNT XXXXXXXX        ICN XXXXXXXXXXXXX    ASG Y MOA MA01  MA18 
1234567891201 120109    22 001 72070 26         38.00       11.45        0.00        2.29 CO-45          26.55        9.16
                                                                                           PR-2            2.29
PT RESP         2.29          CLAIM TOTALS       38.00       11.45        0.00        2.29                26.55        9.16
ADJ TO TOTALS: PREV PD                INTEREST        0.00       LATE FILING CHARGE        0.00    NET        9.16