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P 16B 4BO 104 <br />RECEIPT FOR CERTIFIED MAIL <br />• SENDER: Complete items 1 end 2 when additional mrvlces aro dwirod, and template (tams NO INSURANCE COVERAGE PROVIDED --i <br />P our address In the "RETURN TO" space on the reverse slde. Feiluro to do this will prevem NO7 FOR INTERNATIONAL MAIL I <br />mm being roturned to you. The return rseelot fee wUl provide YW t name of th ersor D See Reversal ~ --- <br />dd ~~ en eve a. Col IRo -- <br />_ r x a) for additional wnla(q rpuwted. ° sem 1' r J <br />Show m shorn dal{vsred, deb, end eddroem's addraw. 2. ^ RMerietad Delivery. o - <br />.itpklsAddrarwtto: ~p~ 4. Ankle NumWr. ~ Str arw No. <br />P p„ Stale and ZIP Code ~ <br />oZe,o-~~ oz.X.o~ y& ~/ ~ i 3 ~, <br />Type of Ssrvica: ~ /J .mac S ,[ ~7 t~f// <br />ry <br />Q t [~Raplebnd Insu o Post e $ <br />~QT,- 17 3 CB.C.rUtl.d CO0 h <br />~~ //y ~ LJ Express Mall ~ <br />~c^,•_` y Certrtied Fee ' <br />/il3JG]SQ / ~r Ahvaye obtain slpnemro of addret <br />__ (0/__~~ ~~ spent end DATE DELIVERED. Special Delivery Fee ~ <br />5. Signature - Addroesae S. Addraswe's Addrco (ONL Y iJ r <br />X rerprcaredaM fee paldJ Restricted Delivery Fee <br />8• ~naturo~nt Return Receipt Showing <br />to whom and Date Delrveretl _ <br />7 DM ~ Return racelpy9howmp tp vdro i <br />~i Date, antl Atldre~ss of Delnary <br />t ~ ~~, RAN m TD TAL Postage and. Fy68 ~ ~ $ <br />s.., , <br />0o Postmark or Date ~ ~ <br />O -~ <br />U. <br />N <br />a <br />