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M/--�C, M— Ic1c65-022- <br />Cer4 i' <br />Fiat M I <br />• Complete s 1, 2, and 3. Also complete <br />item 4 if Restricted Delivery is desired. <br />• Print your name and address on the reverse <br />so that we can return the card to you. <br />• Attach this card to the back of the mailpiece, <br />or on the front if space permits. <br />1. Article Addressed to: <br />Agent <br />C. Date of Delivery <br />is delive address different fro(n item 1? � No <br />If YES, enter delivery address below: <br />/ t 3. Se ype <br />``" t � Certified Mail ❑ Express Mail <br />❑ Registered ❑ Return Receipt for Merchandise <br />❑ Insured Mail ❑ C.O.D. <br />4. Restricted Delivery? (Extra Fee) 0 Yes <br />2. Article Number 7011 3523 0002 9607 5233 <br />(Transfer from service label) 102595.02 -M -1540 <br />PS Form 3811, February 2004 Domestic Return Receipt <br />U.S. Postal ServiceTM <br />CERTIFIED MAILTM RECEIPT <br />(Domestic Mail only; No Insurance Coverage Provided) <br />ru <br />Ln <br />For delivery information visit our website at www.usps.com® <br />M 1 <br />ru <br />Postage: <br />$3.10 <br />C3 <br />C3 <br />R Certified Fee: <br />(Endor <br />Receipt Fee: <br />$2.55 <br />Rests Return <br />r3 <br />C3 <br />(Endor: <br />Total Postage & Fees: <br />$6.11 <br />art <br />m <br />Total <br />Sent To <br />�`---- <br />- --- - -- <br />C3 <br />-- -- -------- --- --- ------------------------ <br />Stree[, APt. No.; � <br />or PO Box No. <br />------ <br />.7V2 <br />Crty State, ZIP +4 5 -4 � % 1 <br />