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1 C] <br />~; <br />Sireel and No <br />~ t~ <br />P O Slale and ZIP Code r <br />o ~~ <br />Postage S <br /> .w <br /> SDecial Delivery Fee ~ .~-+ <br /> ~1 <br />\ <br /> Reslr¢Ied a Fee `~ - <br /> \i <br />, <br /> Relum Re ~ bi' ~tiPYC - <br />N ~~ r d" ~ <br />m Return Receipt showiru <br />Jao whom. ~ ' ` ~ <br />~ , <br />Dale. and Address of Delivery <br /> TOTAL Postage and F¢es 5 <br /> <br />G <br />O Postmark Or Dal¢ N <br />t7 Q <br />E W <br />0 <br />LL <br />~~ f1F /~-83-/tea <br />P 765 476 266 ~• <br />RECEIPT FOR CERTIFIED MAIL C <br />NG INSURANCE COVERAGE PRGVIGEG ` <br />NGI FOR INi ERNAiIGNAI MAIL <br />/See Reverse) <br />l: <br />