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'' - ~ ~ 8 4 5 <br />~~~P~-~~-4'-]q <br />O ~ No Insurance CovP~y"(d~ <br />O ® Do not use for Int atianal Mail <br />e"1 --.-ISne9evnrsnl_ ._ -_ _ <br />BACA COUNTY BOARD OF COMM <br />P O BOX 116 <br />SPRINGFIELD CO 81073 <br />p CerbLetl Fee <br /> <br /> <br /> <br />V <br />l Speual DeL.e,y Fee <br />C <br />( Pestnna0 De~rwrv Fee <br />~ Paru,n Feceipt Show,nq <br />~ m Wnom & naie Debveretl <br /> Aemm Peceip Shown io Waom. <br /> Ddie, antl Atlq <br /> TOTAL Po 9e ~~ ~-d <br /> Fees <br />, Pgslmdf `~'f a <br /> ' <br /> `~\~ ~J <br />N <br />v_° <br />n <br />P <br />0 <br />r_ <br />StNUGtf: ~ - ~ ~ ~ ~~ •~=; ~ r~~ ~-'~'-: i ~ , <br />•CpmPlele itemvtanNor2+or addidonel services. '~ <br />, ~~ <br />~ <br />~ 1 also wish to receive ihe!~• ~'~~ ~ ' <br />•Campele perm s, ae, aria ap. :• . ~ ~ <br />~ <br />', ~.'• <br />~~ : . following services {for an <br />•P~ y <br />o <br />w <br />u erne en0 address on the reverse o+this roan w met we can return fhie extra fee): <br />o <br />y <br />o <br />•~a <br />c` thi ro to the rrom o+the mail ' ~ ~ <br />@ trP pace. or on the becLr.if rpace does not <br />1. p Addressee's Address ~ <br />Z <br />m <br /> <br />• Wdte'Relum Rece7pf Requesrad'an the mailpiece below the adicle number. <br />Z. ~ ResldMed Delivery yy <br />pj <br />•The Return Receipt rill show to whom the snide was deliveretl end the dale <br />delivered. Consult postmaster for tee ~ <br />BACA COUNTY BOARD OF COMM <br />P O BOX lib <br />SPRINGFIELD CO <br />81073 <br />5. Received By: (Pant Name) <br />~ 6. Signatu 8dre ee orA <br />a°' ~( <br />e <br /> m <br />4 <br />b <br />tt -- n <br />Z~(~ <br />~~ <br />R~~ <br />~ <br />(1/ <br />4b. Setvtce Type ~ <br />m <br />^ Registered ,Certified ~ <br />^ Express Mail ^ Insuretl ~ <br /> <br />~Retum Receipt for Merchandise ^ COD m <br />~ <br />7. Date/of~p~~liveryf~ <br />7 ~~ jQ <br />o <br /> <br />6. Addressee's Address (Onlyil requested ~ <br />and tee is paid) t <br /> F <br />PS FonIS 38Y1, Dtxar(ibera(9<. <br />