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'AYABLE THROUGH CANADIAN IMPERIAL BANK OF COMMERCE'S AGENT IN NEW YORK O 4 r <br /> CANADIAN IMPERIAL BANK OF COMMERCE 1.255 <br /> 355 WELLINGTON STREET,UNIT 177 260 <br /> FORTUNE REVENUE SILVER MINES, INC. LONDON,ONTARIO N6A3N7 <br /> P.O.Box 564, 1900 Main Street,Unit 1,Ouray,Colorado,USA 81427 <br /> DATE 09 23 2014 <br /> M M D D Y Y Y Y I <br /> I � <br /> DAY **One Hundred Fifteen Dollars and 00 Cents Only US$***********115.00 ` <br /> U.S. FUNDS <br /> TO Div of Reclamation, Mining, & Safety, Dept of Natl Resrce { <br /> THE 1313 Sherman St, Room 215 u:`#° °':• <br /> OF RDER <br /> Denver CO 80203 o; s%:{b <br /> United States 3iis::•b•�y°i PER <br /> i <br /> 111000 L 5 411' 1:0 2 600 2 5 5811:0008 200 3 309 L 411' 024 <br /> FORTUNE REVENUE SILVER MINES, INC. - U.S. DOLLAR ACCOUNT CHEO 0154 <br /> Vendor ID IName Payment Number Cheque Date Cheque Number <br /> DIV005 Div of Reclamation,Mining,&Safety EE <br /> 000430 9/23/2014 0154 <br /> Document Number Date AmounAmount Paid Discount Net Amount Paid <br /> SEOT23/14PERMIT 9/23/2014 US$115.00 US$115.00 US$0.00 US$115.00 <br /> —rf a ,OS��` 40/ 'se e !/z'l f j' &-114 Q 01,2 - (d <br /> 14114 '. 161—ietrel' 60r-1^174 <br /> US$115.00 US$115.00 US$0.00 US$115.00 <br />