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COMPLETE / COMPLETEI ON <br /> ■ Complete items 1,2,and 3.Also complete A.;Si�gnat / <br /> item 4 if Restricted Delivery is desired. Agent <br /> ■ Print your name and address on the reverse X ❑Address <br /> so that we can return the card to you. B. Rec iv d by(Printed Name) C. Qate of five <br /> ■ Attach this card to the back of the mailpiece, <br /> or on the front if space permits. •C J 1 <br /> D. Is delivery address different from item 1? ❑Yes <br /> 1. Article Addressed to: If YES,enter delivery address below: ❑No <br /> Home State Bank <br /> Attn: Sherry Lightbody <br /> P O BOX 329 3. Service Type <br /> Loveland, CO 80539-0329 KCertified Mail` ❑Priority Mail Express" <br /> ❑ Registered ❑Return Receipt for Merchandi: <br /> ❑ Insured Mail ❑Collect on Delivery <br /> 4. Restricted Delivery?(Extra Fee) ❑Yes <br /> 2. Article Number 7014 2120 0001 8040 1740 <br /> (Transfer from service label) <br /> PS Form 3811,July 2013 Domestic Return Receipt <br /> UNITED STATES PRVICE First-Class Mail <br /> Postage&Fees Paid <br /> 1X3 %'�, + a1 USPS <br /> FINII Permit No.G-10 <br /> • Sender: Please print your name, address, and ZIP+4®in this box* <br /> State of Colorado <br /> Department of Natural Resources <br /> Division of Reclamation,Mining&Safety <br /> 1313 Sherman Street, Suite 215 <br /> Denver,CO 80203 SpecPj-&' 1-:7a <br /> FileVl I°l 3�v3y <br /> rniir�l�ii�irr�rlrlr��rilf ir�(inl�ri�rl�rrr��i�l�hi�rl�lrl�r�l <br />