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^ Complete items 1, 2, and 3. Also complete <br />item 4 if Restricted Delivery is desired. <br />^ Print your name and address on the reverse <br />so that we can return the card to you. <br />^ Attach this card to the back of the mailpiece, <br />or on the front if space permits. <br />~ Q~7 Article Addressetl to: <br />. , <br />A. Signature ~ i <br />X ^ Agent ~ <br />~ ^ Addressee <br />1 <br />B. eceived by (Pri fedN eJ C. Date of livery ~ <br />~s~_~~~~~e~ ; <br />D. Is delivery adtlress different from Item 19 U Ve: <br />It YES, enter delivery atldress below: ~ No <br />/~ n /^~, ~ ~ 3. Service Type <br />/ ''~ ^ ~ ~ (/ - /~ "/'~ Certifietl Mail ^ Express Mail <br />~„,y(/ ~ ~Registeretl ^ Return Receipt For Merchandise <br />1IWWWW~~~~ ^/a~~~ ~ C d ^ Insuretl Mail ^ C.O.D. <br />~~ J Y / a/ 7 4. Restricted Delivery? (Fxtre FeO) ^ Y05 <br />2. Article Number '70P04 0750 0002 1463 3974 <br />(trans/er /rom service <br />PS Form 3811, August 2001 Domestic Return Receipt 102595-02~M-0935 <br />•~ <br />a ~ r <br />(` <br />IT r . ~ <br />m lY' <br />S ~ ri L <br />'~ Postage a 0.83 IRlIT ID: 0501 <br />fll <br />' ° CerUged Fee <br />° Postmark <br />° Retum Redapt Fee Here <br />(Endosemem Requlred) 1,75 <br />° Reetdged Delivery Fee Clerk: F37FD0 <br />~ (Endorsement Requlred) <br />M1 <br />° total Postage a Fees $ 4.BB 06/16/04 <br />~ /J// // / <br />M1 nt o/~<IQ ~r%~7 rf7d ~+ <br />....................... ._..._.._.._yY...._..........._..__.............._.... <br />Street, Apr, No.; <br />arPo SOx NO. ~ Q'. ©p~ <br />Gry, Stare, LPH / Z <br />:r <br />