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<br /> 1 (Me 110ANI "A" 041 hc naqAmd kv nq NEW 11MMI15 ITHIFF DIANCHIS mn 104 111 jAl 1!1�
<br /> INF0RNL1Vk'K),N- �,`HAN,e'A-,,S,
<br /> Bibi'i\
<br /> i ho kmo, Ny.od Kc KN ,ww, so Pimmur APPIA(ANKI kw Ow oAXAI ANN= LVI lti ,RT 0 �f
<br /> 1'ANK
<br /> 4 PRmc ope cc jan Awly at MquWA 55mahom,
<br /> 3 uk; a hmA Nim wowy &MMM"L in am m;Wg 3 OT0
<br /> TOP 01' FURek", 'NIARK 0bR,v 000P ITFhl'
<br /> Alavt an A cn -ihc ,-cx ve on Non Mat bet dmulks Tv reagm IN Gmn B b=g =folved
<br /> FC ' ,11 ( N V IXAAIIJIlSIT15 Ii NF KAl4 �(MJFBE ) jxIJCjTl)
<br /> 1, Rc,�or-d name and sal, ss (Picai looetion) 'of, ilte undoo'gro"'trid lanf(a),
<br /> N(';T; MUSF nwe a vand paysictd ,todudntg city, xtale, and .ata code.
<br /> 11,0, BOX NUINBE-ILS ARB N(YF ACCETTABIJi.
<br /> Indude neares, crows sued and nanx of the
<br /> 2. PN,c nu"wr mum hme an area code If the night, nuncbcr g Ire samc, Cvritc "SANIF' M r0l000ioir,
<br /> A Heck IN approprim, box or INPE (it ?T,`SI',Nj, S OWNITSHIP (cx, COIUIOPATION, INDIVIDL'Al-
<br /> 6, fluk the box for T`yjIf,, OF
<br /> x Facoiny/sii', kxwed wh4c; an lAkm reurvouhn or n3cr In(tAn Irmo Nook choT Me box i"PIN! "YIN"-
<br /> 6kbc of'T'i3O,,-KS Cot dns STYo-
<br /> 7 Rmcnl We LKA, if) # or wroe `3,:0x;,F,' in he k-,r,n,,aJoCd-
<br /> TI. ROPE TY OWNER, 1,K1o`()RMNI7(-)N AC AbDRIoNS lt',4US-T Bli CO3walimm)
<br /> Coulpletc, all ocats, ro, this scctirnl ,mess all hm% an Qe sameors SIXTI(`-)N L If tbC SaMC, ANTH SQA 41; AS OU112
<br /> At welm. Ida sure to neek 11ROPFIn'Y OWNERSI UP "TIF bojC,
<br /> III 1ANK OWNER INFORMA110N A ADDRFS�S BE,(70IN41 11r],'ISW)
<br /> CoyAw ;W ams in At sohn, unlow aU Rms am Me =,-as 'Sl(AION L If the same. sodw *SANG? AS SHIT
<br /> Mis std hal, Ike sate, ua Cra,:ck TANK OWNWAST1111 )fPF box,.
<br /> IV. IX)ARD Of, IjOI-JAIAJJYI'ION US b'SIDRAGPo, N-T NUKI[Tlim(IMUS-1- BF COMPHRIt',D)
<br /> toter your %ard CA' U51P suss arra, its acrouni nwWwr widdi 5 rNuired before Auntrpern,6
<br /> mr; be procenved, Regishmion with do IK X MH crourc, Mat you will tncivc to quarlerly stora„c mc return, in rcpooino, we
<br /> RMN (6 mMQ pm WdIon Ave due on We amber of gpilore; pined hi ymr LTIK Ke ROE will oWn pmam cap" Ani-,
<br /> payong the scorn fQC so rename MH not be WnL If you chy ma Porn e tjaa tacf.,ourn number with, the BOF or ifyu havy ar,
<br /> Twwws repaNg be be or rasa as please Cot! the, BOF,aai 16-323-9555 (sr Write to Me BOF at the fnjlovvhn� adcin,x�'
<br /> Dow, of EQWQMion, Moe 942"179, Sid,,attoento, CA 945TUTI,
<br /> V. PTTI1ZOIJRJ\14 USF FINNANCIA' IIESPONSUDICTIT (IMUST BE 00IMPIXTED)
<br /> LaCrnify the nnechod(s) used by Me owner and/m,opeoitor in nued,ing the I'cderal and State financial responsibility
<br /> requummemm too's owned in, any Ilederal or Stars, agcrocyare axertid frotr$ this requirement,
<br /> V1, AIG AI, N(0110CNTION AND 13113ING ADDRF'!S
<br /> (,'1eck ONE BOX for the address thm all be wed, for B(YI1T I.JC(;A1.AND 11111ING 140171100IR)NS,
<br /> t1PV11CA,NI' ,,M,U4tpS1GN AND 3XVI'F1111C, 110TIA4 AS INUIT K11,1
<br /> INSTURU(7110NI FOR171F, o0(AI,AGENCIES
<br /> 'Ibe countyamd jurisdu'lo-'al 'n"andlers are predeterntincad and can, be obbincd by caHirte, Me &am fhard (9lQ730245. IN:-,
<br /> hwMq numbor note be aoilmd by the Paul agency� hooee,--at, this nuralar must be nurtr(:ricall and Cannot co€1 any
<br /> adohafoctical, If the focal apnq prefers be Qu-, Board to assign the nuciAty nturthm lQue kave A bds nk.
<br /> rr miutf CIT' 111E1,0CA1,AGENCY TIS'yl- INSPE CI'S TI)PEAC-11,11-v Im V1,,RI1CY"11w,
<br /> ACCURACY Olif TIHo INFORMMNITON, '1111S APITICA110N CANN(XIANt PROCTiSSICID IF 11UT 1K)F ACCOUIP114W
<br /> NUMBER IS AKYF HIA10 IN. 710' TDCA, 1,AGENCY IS )ZESIO NSIBI-E FOR3111; COMPI-1,11ON OF'1111
<br /> TID12AL ATUSTCY ISE ONIN' 1NF0R:WX'J`I()N BOX AND FOR FORWARDING ONE 1DR11 'A' AND
<br /> ATI)CINIT0 1QRNM 'IIC(s) T0'I1lE,POTAOWING ADI RF'
<br /> S"I'AUR Of'CA11FORNIA
<br /> �FJ'Nllt W"XIMR, RPSOURCT'S (X)VrR(,)I, JYDARD
<br /> D-NIA PROC'ENSING (TTQT,,R
<br /> PD_ BOX 527
<br /> PARAMOUKI, CA, 90723
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