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MINED \ND RECLAMAiwrv ~ <br />._.,13 Sherman, Rm. ] I S <br />Denver, Colorado 80103 <br />(3t0n~3) 566-3501 <br />RECEIVED I _ tl~ G~-__ - <br />'lo" •Io 19439 <br />DATE ~ ~ - ~~ 19~ <br />nn $ <br />,lain 0 <br />^ CA$H <br />sy~-Cy,DHOECK <br />AMOUNT ~ ACCOUNT..... ... .$ <br />AMOUNT PAID .............. ... $ <br />BALANCE DUE ... ......... ... $ <br /> UI <br />BY <br />