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MINED I D RECL4MATION DIVISION I~~ r 14 2 4 2 <br /> I_.3 Sherman, Rm. 215 <br />Denver, Colorado 80203 DATE ~n - /Lo ~g~ <br />^ (303) 866-356 $ <br />RECEIVED ~ ~ A <br />~ <br /> n~.ilYt .(S77 <br />/17,E] °( bo ~ '~J <br />~•q <br />FRO <br />M <br /> r~ <br />~ <br />~ <br /> • ` <br />1 <br />~p~ <br />~'" `x'~ ~~1~fY ~~/ °t <br />~ DOLLARS <br /> <br /> ^ CASH <br />FDR ~~„~ d p~ ~- ~~-aa ~ ~3~~ ~o <br /> <br /> AMOUNT OF A OLIM. ...... ..$ ~nG <br />AMOUNT PAID . ......... ...... $ ~ „ Il IG (7u <br /> BALANCE DUE ... .............. $ BY <br /> <br />