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Date Sec Req'd: ~j-j'a-5 j am/~~
<br />P~t°•~~~R;IAI. . -3.-~,s'-9 i am~~.
<br />Delivery Date Req'd: L}- /:~ ~-/'~ am/pm
<br />Order Taken By: T~?~; -
<br />~ ~~~~~a~ C~r~ 7°~an~#~~ ~ HHG BILL OF LADING
<br />1~~>; Johnson St. ;~E,~'Sa(em, OR 97',3~!"E
<br />~ 03) :i81-~,;~3 ~(B00) 828-1641 ~ fax (503) 581-692'. B/L Number
<br />PU; ~0373~2 o iCC MC 227345
<br />~ , 3574
<br /> NAME
<br />FISC,~?L SE??VICE-'-tARIOt; COUNTY
<br />ADDRESS FISCA.I. S~RV1CE-i~fiRICN COUNTY
<br /> ADDRESS
<br />
<br />2'LO .~1:Gi{ STRGET 4th "r'i.00K
<br />cirr
<br />STATE ZIP CITY '
<br /> STATE Z~p
<br />S?L~.Ni ~P.
<br />CONTACT PHONE CONTACT
<br /> PHONE
<br />F~Li:~ LYO:V FAX ~
<br /> FAX
<br />
<br />IIIIIIIIIIIIIIIIIIIII
<br />I
<br />I STARTTIME:
<br />III
<br />III
<br />II
<br />6AM 7 8 9 10 11 ~p ~ IIIIIIIIIIIIIIIIIIIIII
<br />2 3 4 I
<br />5 6 NITIALS am/pm
<br />PM
<br />NOON
<br />EXPLANATION: P-PACKING L-LOADING D-DRIVING UL-UNLOADING UP-UNPACKING X•TIME NOT CHARGED FINISH TIME:
<br /> I NITIALS am/pm
<br />MATERIALS MATERIAL PACKING UNPAC •
<br /> KING AMOUNT MOVING UNITS
<br />
<br />QTY
<br />RATE RT OT EXT.
<br /> . QTY. RATE QTY. RATE 1 TRUCK & DRIVER 5~
<br />65 I
<br />:-~
<br />-
<br />BARRELS/DISHPACKS . ,, ~
<br />
<br />CRATES/CONTAINERS
<br /><`
<br />~, ~ ~
<br />1
<br />> ; ;
<br />%-~
<br />~ j ~
<br />i
<br />I'
<br />; TRUCK & 2 MEN - -
<br />
<br />CARTONS: 1.5 CU FT.
<br />SQ
<br />1
<br />Od
<br />'
<br />`/ .
<br />,
<br />:. ; EXTRA LABOR HOURS
<br />
<br />
<br />3.0 CU FT
<br />
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<br />
<br />' (.`..} MATERIALS
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<br />-
<br />,~( i., 1
<br /> , ~ - ~ _ ~~
<br />- ~ .< ' 1 OTHER
<br />4.5 CU FT -
<br />
<br />6.O CU FT i
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<br />WARDROBECARTON
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<br />MIRROR CARTON
<br />SI
<br />~
<br />BTOT
<br />AL -
<br />~~ -~i /
<br />MATTRESS CTNS: siNG~E
<br />
<br />DOUBLE
<br />.SQ
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<br />: TAPE ~ S 2. SC ~. =-~:0 o
<br />0
<br />STICkEF.S . C
<br />SUBTOTAL - -~ ~~{.`>~
<br />
<br />~ . . SUBTOTAL -
<br />
<br />If the shipper declines to sign this declaration of value and the shipment is accepted, . .
<br />DATE OF PICKUP qEOUESTED DATE OF DELIVERV REQUESTED
<br />the shipment will move at the depreciated value protection level and the shipper will
<br />be SUbjBCt t0 th@ epp~Opfi8te v01U8tI0n ChB~gBS. SIGNATURE/AGREEMEM TO HIGHEP CHARGES DATE SIGNED
<br />^ RELEASED VALUE PROTECTION: j'
<br />Goods wili be valued at gP, ce~
<br />yEr Ib.,per article. ~• .
<br />~
<br />~
<br />Shipper: ~" ;~_ ~. ~!' ~ ;'~~:tc,/~l ~`C_ Date: ~' , c-~ ~I ; ,~~ ~ GROSS W7. TARE WT. NET WT.
<br />
<br />^ DEPRECIATED VALUE PROTECTION: Goods will be valued at $1.25 times the MILES: ~
<br />actual weight of the shipment. For each $100.00, or fraction thereof, of declared value
<br />at $1.25 times the weight of the shipment in Ibs. or declared lump sum vaiue, wn~cnever ' CHARGES'F~onn ..oo`.~ ~
<br />is higher, the valuation charge shall be 50 cents per each $100.00 of value. OTHER CHARGES
<br />Shipper: Date:
<br />
<br />Lump Sum Value: STORAGE CHARGES
<br /> ~
<br /> ~
<br />VALUATION CHARGES
<br />Q REPLACEMENT COST PROTECTION: Goods will be valued at $3.50 times the
<br />actual weight of the shipment. For each $100.00, or fraction thereof, of declared value TOTI~L CHARGES, ~Q ~~,~5~
<br />at $3S0 times the weight of the shipment in Ibs. or declared lump sum value, whichever
<br />is higher, the valuation charge shall be 85 cents per each $100.00 of value. ADVANCE DEPOSIT
<br />Shipper: Date: r',~ J~V J( r r r~~ "~~' ~~.~ .~ 7. i
<br />Lump Sum Value:
<br />BALANCE DUE~ ^
<br />; ~Q9~Y,~~, '
<br />.. .-
<br />a copy of the
<br />t the first contact with the carrier
<br />i
<br />d
<br />I
<br />k
<br />l
<br />th
<br />t I h
<br />d
<br />C.O.D. ;BILL i PR
<br />EPAID
<br />,
<br />ve
<br />, a
<br />ac
<br />now
<br />a
<br />ave rece
<br />e
<br />ge
<br />form entitled GENERAL INFORMATION FOR MOVING HOUSEHOLD GOODS OR ~ T S NOTED:
<br />RECEIVED IN G09D CONDITIO
<br />OFFICES IN OREGON which explains the Oregon rules and regulations affecting ,
<br />~-~, p -
<br />~
<br />oods and office furniture and fixtures.
<br />me~ts of household
<br />intrastate shi nee:
<br />~' --
<br />Consi
<br />p
<br />g
<br />I understand that my final charge for service must be based on rates that have been g
<br />%• ~.~ -- -
<br />!
<br />~
<br />approved by the Public Utility Commission and published in a tariff regardless of any Driver: ~""'
<br />`~ ` -``~
<br />estimate for service provided to me by the carriec I UNDERSTAND THAT AN ESTIMATE COMMENTS/EXCEPTIONS:
<br />IS NOT A FIRM BID.
<br />Dated:
<br />Shi
<br />er:
<br />pp
<br />Carrier:
<br /> WTB NO. 50
<br />
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