| Name | [A. Name] | Status | [Created] |
|---|---|---|---|
| Nominee Name | [Nominee Name] | Amount | [US Dollar] [Amount] |
| Nominee Address | [Value] | Foreign Currency | [Foreign Currency] |
| Creation Date | [Date] | Payment Method | [Cash] |
| Effective Date | [Date] | Check Number | [Value] |
| Bank Account Number | [Bank Account No.] | Voucher Reference | [Value] |
| Bank Sort Code | [Value] | Ledger Reference | [Value] |
| Invalidated | [True] |
| [Message] |
| Case Reference | Product Name | Type | Amount | Credit |
|---|---|---|---|---|
| [Case Reference No.] | [Benefit Sample] | [Type Description] | [Amount] | [Amount] |