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v i -5 — U$�t <br />�C-15 <br />CeAl <br />• Complete items 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 />- -i <br />Mr. Randy Schafer <br />Phillips County <br />221 S. Interocean Ave. <br />Holyoke, CO 80734 <br />A. Signature <br />/� // ❑ Agent r, ,,- <br />liecei 0 b"'Printed Namer C. Date of C <br />� , � � y mss. <br />D. Is delivery ddress different from item 1? ❑ Yes <br />If YES, enter delivery address below: ❑ No <br />3. Service Type <br />21 Certified Mail 13 BWM Mail <br />C] Registered ❑ Return Receipt for Merchandise <br />❑ Insured Mall ❑ C.O.D. <br />4. Restricted Delivery? (Extra Fee) ❑Yes <br />2. Article Number <br />(Transfer from service label) 7 012 3460 0 0 0 0 6384 6 4 0 2 <br />I PS Form 3811, February 2004 Domestic Return Receipt <br />102595 -02 -M -1540 <br />Postal <br />CERTIFIED MAILT. RECEIPT <br />omestic Mail Only; No Insurance Coverage Provided) <br />p <br />C <br />M <br />ry� <br />Postage $ <br />O <br />Certified Fee <br />0 <br />C3 <br />Return Receipt Fee - P tmark <br />(Endorsement Required) r here <br />�i <br />O <br />+ <br />Restricted Delivery Fee <br />C3 (Endorsement Required) <br />�• <br />Total Postage & Fees $ <br />M <br />ti Sent To Mr. Randy Schafer <br />o Street, Apt. No.; Y '°-------------- <br />or PO Box No. Phillips Count <br />�, o. <br />City Siate, ZrP +a 221 S. Interocean Ave- ----------------- <br />:rr Holyoke, CO 80734 <br />