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<br /> Telal Posmga 5 Fees ~y .... l°C; t~'r'!.!~i
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<br />~ c~YI S'~r!'1
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<br /> or PO6oa No.
<br /> City, Sb%LF4d
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<br />~ Pbstade S ... 11;11 i 11 ~...
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<br />O CaNimd Fee
<br />D Poslmerk
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<br /> (Endorsnmani flBqulrad) ~~~ • ~ -
<br />~
<br />~ Reslriclnd Delivery Fne L :`~ !-' - i is
<br /> jEndorsanrnnt RayuireJ)
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<br />
<br />Teral PUStaga SFeea $
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<br />I ~! ~/rjy
<br />m
<br />~ ont To
<br />
<br /> SGeaf, Ayf. NO.;
<br /> nr PO Dnu No.
<br /> "nY, StBle, ZIP~-0
<br />
<br />,i ~ {'i3
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<br />M1 . 3
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<br />~i /a _ I
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<br />~ l g}:~d~ ~ d r l w i f?:1i49 ~ .9"".A. ~ .. yj i.„:~
<br />~ Postage S ., 'I 1~18Y-TI ~}rh ~-~
<br />~ . 4 rf
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<br />> ~•.
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<br />Cemliad Fee ,
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<br />O Return Reclept Fee
<br />I Poslma~k
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<br /> (Endorsement flegblred) , ~
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<br />'~ Resaided Delivery Fee iy.)
<br />~ i' n•
<br />.
<br />elfh':('
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<br /> (Endo!samem Reyuirnd) :
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<br />Total POSmgan Fees
<br />~ '•`"-
<br />/ ~1 ~'~04
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<br />O enf O ,
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<br />ar PO Hn. o.
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<br /> Posmge S 'l, ;S'j I~P}Ir •J II,; r-j~;,i
<br />ITT
<br />~~ is ;~ ~~
<br />~ Cerillled Fee ~....--
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<br />Vuslmy rk
<br />'
<br />Q RBWrn flnclept Fee (
<br />I tr;f _
<br />HbrB,
<br />O (Endorsement Regblred) q , , f/y ; ,, , ~_
<br />~ Rb6eIC1B0 Delluo7 Feb L,jl {; ,; ( jrlji!,' ~.
<br />~ (Endorsement Repulred)
<br />~
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<br />Total Postapa 8 Feea
<br />$
<br />!!.:
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<br />
<br /> S1reef, Apt No.; V
<br /> or PO f3ox No.
<br /> Gity, SIeIB, Z!W 9
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