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I mp—rlii i it Rt,,jzar,,,,i '0(-1 Pa,'c I, It informat["[1 I� 11-11, Compl-c-tv sse N%III 'INC to proee— in a tinleIN T-na-Incr. <br /> Part 13 <br /> I'll N Ce Purchaser's \Iolle% 01-dur C killn <br /> -J —1, T'I"tcl, -I it t!", <br /> J I o— 11, a p J-1 i t h as,.j I I n 2 S I 0 1,T r -1r j it 1 "11 C-I Z.p-I I L 1 1 f u T1 j I v, 1 <br /> ro r.I cl.h It to for <br /> Part C <br /> Si nature of Claimant' A Si-,nature of Joint Payee Claimant <br /> Identification Identification <br /> Issuer*umber- Expire Date 11 Issue Date lype ;umber* Expire Date Issue Date <br /> Important Important Signature(s)must be notari:ed ifclawraw is not present to sign <br /> and i(wjhle r)1,rm i,,k ei--ccpiahle primarl identiricalion ii tilt photo /wiles, and unable to provide acceptable pritnarj,identification with photo <br /> L'0nIj)lL!11!J hl 0 bUll! a 13 OCIL112) <br /> 'FolloN%ing section must be completed by a Notar� Public to acknov ledge identity of claimants unless proper identification has been <br /> obtained for the claimants completing stop pa}ment form. A notary public is not required if the Declaration of Loss and Indemnity, <br /> kgreement is signed bN a bank associate. <br /> IndiNidual \cknosNlcd,etoent Joint Pace kcknmsICd1,1CnICot Non—Individual Entity Ackrioy%Iedgenlent <br /> P 'in, !i milhil'IL'C1,11111C117t L01111)1t'le bl-)I;l %JMI!of il C1LI11?HV7r 1,U hUSMI!s's or 01;11!r <br /> \LTML'of('V1?2j1LV7j S L'11CM <br /> Nalne of,Clami'MI: <br /> \arnc of Claimant <br /> NO I kRN KNONN LEDGMEN-1 it! <br /> Coun!" A <br /> r r, t Yj <br /> i.,, j-2 t; <br /> 1ICLk One: <br /> I HIV, I UNI at Thnanci.fl enter or Others Pro-- <br /> te'! 1"wl C) <br /> -ve <br /> ---V4 <br /> It <br /> Rk!c�)nci]Llitiml Tvani 87-66-5-1224 <br />