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• Complete items 1 >-d/or 2 (or additional services. <br />• Casrpfate items 3~ ~~ 4a & b. <br />• Priq[ your name a~A•Address on the reverse of this form so <br />that ,Ni9 Can return this card to you. <br />• AFi~h this form to the front of the mailpiece, or on the <br />back if apace does not permit. <br />• Write "Return Receipt Requested" on the mailpiece next to <br />jiana Department of Natural <br />vision of Reclamation <br />~. Box 147 <br />aonville, Indiana 47438 <br />5. Signature (Addressee) <br />6. Signature <br />•us. al>o: toad-sraea, <br />S Lt't+ <br />~ ao-oP' 179 165 594 <br />:O <br />U <br />d <br /> <br />CCV <br />C <br />Q <br />C <br />td <br />C <br />~ m <br />~ m <br />~ m <br />(7 J <br />T ~ <br />~~ <br />tT~O <br />J f+l <br />E <br />,LL <br />~N <br />d <br />Receipt for <br />Certified Mail <br />No Insurance Coverage Provided <br />~.uo~ Do not use for,I,ptfr~national Mail <br />ISee Raver Af A \ r <br />S em m . M , 4 <br />Cc <br />Sveei an o <br />ao n oA <br />.Sias a~tl bP Co J - ~ <br />O' <br />Postage <br />Cen ilietl Gee <br />S Ream Deeverv ree <br />flew m~ed Delivery Fee <br />Peimn ReceiPi Sgcw~ng <br />~o WM1Om & Daie DeGVereQ <br />aeiwn eeceiP~ Snomng io Wnom, <br />Daie. antl AtlG~essee's AtlUiess <br />*niAl Postage <br /> <br />'rUStmdik or Dale <br />I also wish to receive the <br />tollowing~ices (for an extra <br />fee): <br />1. ^ Addressee's Address <br />2. ^ Restricted Delivery <br />4a, Article Number <br />P ~ 7q 16S 590 <br />RE54b. Setyice Type <br />^ Registered ^ Insured <br />Certified ^ COD <br />^ Express Mail ^ Return Receipt for <br />Merchandise <br />7. Date of Delivery <br />L l~~/1_C1~ <br />and f€e is paid) <br />RECEIPT <br />