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,1- <br />~ ' <br />!il <br />rR <br />IL Postage $ t r ~ ..__ 4 ....1 (~:-"`. <br /> <br />~ Certifietl Fee 3 (~ ~ A; <br />,,,n ,;,~ <br />m <br />Q Retum RecelP[ Fee <br />(Pntlorsement Required) ' ~ ' ~ fe ~(I N <br />IJ' ) <br />I O Rendcted Delivery Fee <_,'~9 <br />~° <br />' <br />1 O <br />~ (Endorsement Required) = <br />~S <br />'/ <br />~ <br />I <br />~ <br />' Total Postage fl Peen ~ l . <br />y ^~ c~ <br />/ <br />~ <br />\ <br /> <br />nJ _ <br />__ <br />I N Name (Pleas 6e completed by mailer) <br />i re ~' •" •~ <br />.t~~ <br />-- -~ <br />~-. St <br />et, APt. P Box a. <br />r <br />. <br />`~ <br />8 <br />~. . <br />. Box ia~ <br />C` j~ <br />C1ty,State, P+~}~AI Gt CO 81626 <br /> al <br /> <br />rR <br />a <br />Bua-c o~ l-a.-d <br />oCv-"~e~ <br /> <br />fU <br />Postage /] <br />$ r 3 / :J, <br />.~/',~n <br />~ Certifietl Fee 3 V \ ?/, l3 ~ ~ <br /> <br />~ Retum Receipt Fee <br />(Flldoreemenl Regllim(f) <br />~1~~~ Ha <br />~ Restdcletl De1Wery Fee <br />O IEntlorsement Required <br /> <br />~ Totat Postage 8 Fees ey <br />nJ <br />N Name (Please Ptlnf Clearly) (ro 6e completed by mailer) <br />m - <br />~~----Q-(~---f....Minty~y---fin ~.-----~.;--~=----~=~._....- <br />~-. Streeq Apt. No.; or PO Box No. (1 <br />' ~ City, State ZIP+ 0 <br />I` C'A 21 c• z(. <br />:r. <br />U.S. Postal Service>Ta i <br />ERTIFIED MAILTM RECEIPT <br />( omesfic Mail On/y; NOinsurance. Coverage Provided) <br /> <br /> M1 <br /> M1 I Postage $ i"-~ <br />c-; , <br /> 0~ Certified Fee ~ ~~ i ~~ ~_ <br /> <br />r <br />jj <br />• <br /> <br />Realm Reciept Fee <br />(EntlorsemeM Required) <br /> <br />' <br /> <br />~ ~ <br />~10rk' <br />~~~PPPo '\ ~, <br />e're <br />t <br />i <br />~ <br /> , ~ <br />i ( <br />~ <br />` <br />~ <br />'~ Restrkted Delivery Fee <br />(Endorseeient Required) t <br />% ~i , <br />t~~' <br /> \ <br />irq <br /> <br />Total Postage & Fees <br /> <br />$ <br /> <br />~ '~~';. %i <br />~s"-. <br />~ Cc i -~ [j i <br /> <br />p <br /> <br />rv Se ;f ro <br />..4.~li~i..(~_)_-~if_P..!!~PC_f <br />Sh ~^ . <br />_llY]_tJ~yw/w_~_~¢rYl-!~-- <br />_ _ <br /> ea; f. NO.; <br />or PO box NO. <br />I <br />~ ub <br />~ <br />~ C J~Y1 <br />'S~ (~ ,y, y <br />J <br />u ~ <br />3 <br />~~ <br /> , <br />- <br />_ _ <br />_ <br />. <br />Giry, state, P+4 <br />l Cn>•~r. Ga ____ <br />. <br />023 c._ <br />- <br />_4~. <br />___. <br />51 <br /> <br />~ 1 <br /> <br />I <br /> <br />rR <br />M1 .c5 tom-/ t. r~"`t, 'r ~c,• S1~ <br />, t t <br />t <br />L <br />' <br />vi <br />' ' GS <br />' <br />J <br /> <br />` l'i <br />t <br />i <br />:1 <br />1- <br />~{.. Izez ti <br />~ i:u <br />fi: <br />r <br />Postage $ / C~~ -~'-. <br />'-~' <br />~ <br /> <br />if <br />. <br />~. <br />'~ <br />~ ~ <br />Cert <br />ietl Fee <br />~ <br />3o i, ~ : <br />, <br />' <br /> ~ <br />~^. A <br />? <br />O <br />~ Retum Reciepl Fee <br />` , <br />G <br />Po <br />~ <br />( ~ i <br />(Endorsement Required) ~ <br />' , ) .,- ~ it I <br />O Restricted Delivery Fee 1 ~\~~~~~0 i <br />~~ <br />~ (ErWOmemant Required) 1 <br />t <br />.d <br />Total Postage & Fees <br /> <br />$ 4• yy \ <br />' <br />/ <br />m <br />p sear r <br />N Street, Apt. No.; ' <br />orPO Bar NO. so~._____~C~ Q(~l,s _.. /(.~~..~ <br />Ciry, SYafe, ZIP+4 - /y----T ." .......................... <br />~~~\1 ~/-l ~~7i~ <br />I, <br />' CERTIFIED MAILTM RECEIPT <br />(Domestic Mai! Only; No Insurence Coverage Prc <br /> ' ~ ~ ~' ~ <br />i <br />'~ <br />~ <br />E <br />M1 C~ Ca <br />J <br />t <br />ms <br /> <br /> . <br />~,'` <br />~ ~ <br />Certifietl Fee <br />a ~ `"~ <br />o r ~ s:. , <br /> <br />p Realm Reciept Fee <br />~} ; <br />~ Pee <br />~ _-. <br />(Endorsement Required) I <br />- { y (• ~- <br />t <br />~1 <br />. <br />% <br />• <br />~ ResVictetl Delivery Fee <br />~ , i <br />. <br />,~ <br />,,, <br />~ ~-' `• <br />" <br />~ <br />~ <br />(EntlorseneM Required} <br />U ~ <br />„•~~ <br />.. <br />~ <br />ToW Postage 8 Fees ~ \S <br />~_ <br />m <br />o sear rq ~- y~ (`[ ~t_ <br />~ _,.PI 1~:-r~~ C.qU.~ tiJIY..I'At~(_MW3° <br />or PO BOx Na. ~ `~~1 ~ ~_ v ~____.[~.,~_ ..w~x.'.~~ .............. <br />--------------------- <br />CiN. Slate, ZIP+4 ~ ~I~ <br /> <br />~ .. <br /> ) <br />r ~~ ~ ~ ~' ~ q i~ <br /> <br />M1 <br />Portage <br />$ <br />, <br />~ <br />~ ---~\ <br />~ ~ <br />Q CeNtiad Fee ~ ~/~.`i <br />~ <br />/ <br />O Rehm Reciept Fee <br />(Endorsement Required) <br /> <br />~ Postmark <br />' <br />/ \ T. ` <br />t % r,~ Here <br />~ <br />~ <br />~ Restricted Delivery Fee <br />(Endorsement Required) ~ ~ ~ r`~' ~-U \ i ~ %! <br />` <br />~ <br />l=; ~' <br />' <br />r~ r <br />- <br />~ <br />~ <br /> Total Postage 8 Fees $ <br />~ ~ ~ <br />aV <br />2' <br />~ <br />~ <br />r^ ~ <br />O <br />O Sent To <br />' <br /> Sheer. . No.; nn ` <br />or PO BOx NO. <br />~/ <br />~ <br />~ l <br />1~ <br /> _____.... <br />___ <br />~I <br />Ciry, state, ZIP+4 __- <br />_____________ _.-...._________.....-. <br />