|
~1 •
<br />II
<br />~r1
<br />,. ~ I
<br />1
<br />1
<br />1~ i
<br />./~
<br />".•-..a
<br />`~{•,.1 I
<br />-, ~ -r 1
<br />. ~ I
<br />!a`I`.. V
<br />,,._ ,
<br />'~: : •~
<br />^t1 ,7
<br />yI ~rlh+a rl~•:. '1 Il lrlrgvinl irn n..•:rn,l ,. in.• ~I nr ii•: ,..,rr .J,
<br />I~~'~~It}1'~`~("~•~1fP`'+~ry'•41?~1~(IL~:I! nrllnirl~ .>.i',•jer 'rt.:l.,.,•
<br />r
<br />41A 7..)IVl ~. ,! y 1, { .,, e~hli n; ul r'• Lln nn1 ver 11" m.ilG n'. .;~1 ~ .I ~i 4~ 1'•'a.ril•.tl •y 1
<br />,rla•.d '.1.t'. a,,.u.'.4 ~,I•: .~:. :.1 _... _.__ ... ... ._. _. _...._. _.• - __ - _ _- (:. _.. ti. :,. .. J:..,.L.l:
<br />2. M'nk "Y." in lhl: rluv i 'n. $I ale Penni( Fh rrnl!cr 7y~30 ~ .. '1. r.al~,r; •lu ri1,l„L.:r
<br />I( fist lenort
<br />_ _ C __ ~ I.lb, Er,nhnunn D;nr-_------('0000 - - -`-- _ 0502!,61 01 ~ ~
<br />5. Nome nhl)n~l l;tl!u r5n2461 IG. Plamr. of 1'rl mitir, r, -~~~.~-- _-
<br />4VYU,IIt1C; FUE1, r. l;rll)glar
<br />r,inJnn~ r\dcry r;s i - - .--'_~__ .__-_. _._- h.'lad'irir}ILirldf~rS II ~I`.'ll U; ;;i it DS V'.
<br />Pll It(1;( 152b5 A11t1 CNULI~ ~I;i~' _ _ _--
<br />(lil,...._.-__ '- .__ - LEI ;iIG-"'- -____.- __-17_in (., Ill r. -. (.II`/___.-_-__._- I$l,lrn-_ IZrf, (;r
<br />L~~Y.F.Wf?I)0 CO r.ht.15 0
<br />--------------------IOCnT10NUFMINE ------
<br />/, Fia"~c M Mrir ~-~~ -_-~ R. +:^tn'h! 05j 9 $Idn!--~f) 10. rVcarest Tnvdn
<br />_ 1-- ... -- - -- - - - -~
<br />SIrnp 11ItaF;rn'IAUTAI. Cunt Jnf,k5o'I Cn
<br />1 ), N]IIIP, OI COnla^+. I'e'SO~I fhleph nne PJ ~.nnhrl 12. Indian RescrvaUOn and/or Trlt,r.
<br />I .
<br />3~3 `~?9-17u0
<br />~~~•~i~ ~'s~~ jsg;.;!',.'i.'•f;; r'- -`--- 13. Pfil.)DUC PION nNL) F[f_ COMPUTnTION _ __ __ ~ 1 ~!
<br />(anal rninlnll rn~worl I•luinll^I nl I"n: I nq 'r'r Inn -_
<br />`iu6p•rl +'• the 1-r, r. Jl,li ~l laird I'r'i Lrnt aq'• Doll:us I r
<br />(,) Ib1 1
<br />pa II11 ~'._h ----4 L_
<br />$.I.lat.~' ~ 35 cents u. cents is 7 ~ Z 20 -
<br />S Ib6ituminml5 x 15 Cents rn cents°S
<br />' LJncrcnp nimd
<br />._ _.___-.. _ __ ~~.,. __-_._- _.--_-_-_ __--___ ___I
<br />I' rl ~1 '~rl •''•~' ~1•;'ri f lU t:rnl.'. nr f.CnlS"~
<br />111.1 nIC •~). 1:~ I` 11 I i
<br />14. I: •rlnr,hr'n', rn l,ILLUr,n; tllh~niily by II!•m flu ndlgr• )!i. C)ShA IJsc Clnl•/
<br />nllarh $I n•~" II Mnlr ~pd[p it N,:,:(Iclll. _ _.-___
<br />I t, 1 . Nn.
<br />... I l.. ~iJ.. :A' ~ ~Ip .!~I~
<br />f v1.J Plan l n II„ Parrl IJI, 1_~I 1111 l hart l h~n ly I~fUI (J d','S nllr,r Thr, 6n,1 .__.
<br />!If Ihn C.d••r"I:r r]i i.n lcr ._.- .._ _...._ _.._. .. _____._.. . __
<br />10. tl~ldcn, Co.l.':n'ndo
<br />/iclinn f Tl ansaclion No,
<br />_.-_ I__, .I-_-
<br />Pay
<br />S j)22n ~i
<br />nrruUnl
<br />ftEGIUN''
<br />
<br />PLEASE IiF2lTE rf1ItIC IU 05026bi O1 gt r.rnv t Co(L:
<br />______--
<br />UII-YC~Uf? CHECK
<br />------- ---_ ic'tlihlCndt~ -
<br />--
<br />`--- Call the loll frr;r. number (1;001 251 "9302 i( you have any problem with tlr•
<br />wauonal ran r-ree N~Inb,:r ar any other prol)lem re~larcling [he rCr.lamntion Ice.
<br />__.
<br />ISfr~'~1µe~;%1~+4'Ihl'„i',I~;b: 1G.CEf1TIFIC/1
<br />~~ - r.
<br />TION
<br />"1"~4r {'' ~~'.~`
<br />,
<br />:
<br />1,.1 III!"IIPn~'CI'I+1ItJIl,.lf wn '.Itil"rnr ntt ln.r~tc hrlcin ---- -- -
<br />(d.l Subscr8~cd and Sworn to nnr!'?(7icl, O.t~1t_D.r.
<br />7
<br />arc Ilr", Cnrrl•Ipl r, and cnlinr;t to ih~• hr'•d of u,y F:nnw~ ;J .
<br />ilU]. 1J_R.~ , in ,[hnjh es?nCC.ot
<br />y L. -
<br />~~"
<br />IPrl tlr .)nJ LgYlnl, Ilntl .lrn Intl lr In gnarl fa~lh. r _ .~ ~•
<br />.
<br />(`
<br />It).) I'Jdinr rtl v1+urllnq IiGsOn, erlrl'Or.lte OIIIC^.r, Tlp;nl Y)r -
<br />•~ .,
<br />r~
<br />(lilt Ctrl, n0 11rl6ill ,.)t the hlrC~alnl, DI IhC phCldllll !` I$~n(_I ~~~'~._
<br />~ ,
<br />~/ l
<br />~ l
<br />(Ininl In Ink pl f r.•I
<br />vl
<br />.,,
<br />I.1'''::illi~nl
<br />I ....
<br />~: ~ q~ ., .,I~
<br />r
<br />r_c-.
<br />..
<br />.
<br />'L
<br />G
<br />L.v:
<br />1 c
<br />;
<br />.
<br />c,ll
<br />Paul. C, ;
<br />,
<br />~
<br />~
<br />~
<br />.~~.,,
<br />,
<br />_~ _ ~. '~u,„------
<br />lc.l Sigualu~ ~ ~
<br />~ ~'~ ~ I rt ~ f7 1
<br />~ r.lorngvPUlsl_Ir, ,7al~u~.
<br />.:.
<br />~+l
<br />'
<br />r
<br />~
<br />~ .. __.-_._ ~
<br />\1 ~. . (
<br />r
<br />_ __
<br />My Culnnnsmn f.xlru cs
<br />;; r ~ ..., Inm 71l i`r •:nin- Ir..n qNy n•'•Sn n, r."PV H~ nllr~~ rr nrl ~ •Y•r.:', nr, Un Il rl. plf Of n Ceal nunr, Mlo,r al nr vrhn I
<br />- ~-r nL' lt) 1I
<br />,
<br />r.r,rr •.., ny Ld:~ L, L.r,,•.ni• ~..L. r..~.nlai n.,, .,, r^r 1'be.n n,, •,, u. hr.,•.:~„•Jv la
<br />l,c nu nl Jr~:d hV . hu,~ pl apt mui ^ tha
<br />n
<br />lJo
<br />1 ion th all
<br />uP^~r c^.imL Up n ~i•. in „r.rty ; sl.~lr~,'.en t, rrnre;enlm rqn n. car tllrc.+:~.,
<br />n :pl0flilll, ur by ,rno, nnonrenl for not nuurt than one V"
<br />,
<br />,,
<br />.
<br />.n I
<br />;
<br />f1A~.G ) f'.I IDI?I'1 )(l (1 lA
<br />STIPULRTIUN #25 1'lli lrgRf 1 Ih nrgr.I l~r.n pll.ll (`••
<br />_
<br />
|