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MINED LAN[ CLAMATION DIVISION N 0 ~ ., 0 2 0 1 <br />1313 S~~rman, Raom 423 <br />Denver, Colorado 80203 <br />6-3567 _ DnrE ~ is ~ ~ <br />03 <br />86 <br />(/3~ <br />() <br /> / <br />~ <br />~ <br />1 <br />~ <br />RECEIVED FgpM l 1U ~ / 1 • <br /> (~ <br />THE SUM OF ~ M ~L `,DOLLARS $ <br /> <br />ECK <br />FOR ~i1'l OLiCY' ~/ 1 "' ~ ~ " ~ I'~ K C~O.~Y ~ cns~-~ <br />MO <br /> <br /> AMOUNT OF ACCOUNT...... $ <br />and oul <br /> AMOUNT PAID ................ $ / ~~ <br /> /~ <br />BALANCE DUE ............... $ BY ~• ~\.li~RlY" ~V.l <br /> <br />