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Receipt Page 1 of 1 <br /> ae,Lf5 3o <br /> United States Department of the Interior <br /> Bureau of Land Management Receipt <br /> DIV OF SUPPORT SERVICES <br /> 2850 YOUNGFIELD STREET <br /> LAKEWOOD, CO 80215 -7076 No: 2860866 <br /> Phone: (303) 239-3600 <br /> Transaction #: 2946729 <br /> Date of Transaction: 08/21/2013 <br /> CUSTOMER: <br /> DANA J CACCAMISE <br /> 1040 CROSS COUNTRY DR <br /> COLUMBUS,OH 43235-5138 US <br /> LINE IQTYI <br /> DESCRIPTION REMARKS PRICE TOTAL <br /> LOCATABLE MINERALS /MINING OVER PHONE <br /> CLAIMS-NOT NEW-UNADJUD,ONE PAYMENT FOR 2014 <br /> 1 1.00 AUTH NO. ONLY/ MINING CLAIM MAINT. FEES 21 - n/a- 2940.00 <br /> MONEY RECEIVED CLAIMS CMC 284530- <br /> CASES: CMC284530/$2940.00 550 <br /> TOTAL: $2,940.0011 <br /> PAYMENT INFORMATION <br /> NOTE: Items will appear on credit card statement as "Bureau of Land Mgmt CO". <br /> 1 AMOUN 12940.00 POSTMARKED: N/A <br /> TYPE: CREDIT CARD RECEIVE 08/21/2013 <br /> NAME: CACCAMISE, DANA J <br /> 1040 CROSS COUNTRY DR <br /> COLUMBUS OH 43235-5138 US <br /> CARD NO: XEXXXXXXXXXXX5786 AUTH CODE: 197847P <br /> NAME ON DANA J CACCAMISE II <br /> CARD: <br /> EXPIRES: OS 14 <br /> SIGNATURE: <br /> REMARKS <br /> This receipt was generated by the automated BLM Collections and Billing System and is a paper representation of a portion <br /> of the official electronic record contained therein. <br /> http://cbs.blm.�,ov/cLibin/cbsp/zorder — 8/21!21013 <br />