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3/12/24, 10:26 AM Receipt <br /> United States Department of the Interior <br /> Bureau of Land Management Receipt <br /> DIV OF SUPPORT SERVICES <br /> CO STATE OFFICE, PO BOX 151029 <br /> LAKEWOOD, CO 80215 No: 5366464 <br /> Phone: (303) 239-3600 <br /> I Transaction#: 5523735 <br /> Date of Transaction: 08/12/2024 <br /> CUSTOMER: <br /> GEORGE L QUIST <br /> 1849 TRAIL CREEK RD <br /> LAKE GEORGE,CO 80827 US <br /> LINE IT <br /> QTY DESCRIPTION REMARKS PRICE TOTAL <br /> MLRS MINING CLAIMS/MINING CLAIMS-EXISTING- <br /> MLRS ONLY/PROOF OF LABOR/ASSESSMENT <br /> CASES: C0101312051/$15.00, C0101313130/$15.00, <br /> 1 10.00 C0101314486/$15.00, C0101316649/$15.00, -n/a- 150.00 <br /> C0101338549/$15.00, C0101339213/$15.00, <br /> C0101423463/$15.00, C0101425663/$15.00, <br /> C0101425686/$15.00, C0102521436/$15.00 <br /> TOTAL: $150.00 <br /> PAYMENT INFORMATION <br /> 1 AMOUNT: 150.00 POSTMARKED: N/A <br /> TYPE: CHECK RECEIVED: 08/12/2024 <br /> CHECK NO: 1405 <br /> NAME: GEORGE L QUIST <br /> 1849 TRAIL CREEK RD <br /> LAKE GEORGE CO 80827 US <br /> REMARKS <br /> NOTICE(S) <br /> Notice to When you provide a check as payment, you authorize us either to use information from your <br /> Customers check to make a one-time electronic fund transfer from your account or to process the payment as <br /> Presenting a check transaction. For inquiries,please call the BLM office listed above. <br /> Checks: <br /> Privacy Act: A Privacy Act Statement required by 5 U.S.C. § 552a(e)(3) stating our authority for soliciting and <br /> collecting the information from your check, and explaining the purposes and routine uses which <br /> will be made of your check information, is available from the Federal Register at: <br /> (https://www.federalregister.gov/articles/2003/02/04/03-2521/privacy-act-of-1974-as-amended- <br /> Ittps://ilmocop0ap6165.blm.doi.net/cgibin/cbsp/cbs_start2 1/2 <br />