or download this
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