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Z 016 974 006 <br /> Receipt for <br /> Certified Mail <br /> No Insurance Coverage Provided <br /> Do not use for Intern tional Mail <br /> (See Reverse) <br /> S io <br /> �et and I' Q <br /> OU <br /> P. ,State a P Code C r33d <br /> J O <br /> Postage F p <br /> Certified Fee 9 <br /> Special Delivery Fee <br /> Restricted Oellvery Fee <br /> TReturn Receipt Showing <br /> W to Whom&Date Delivered <br /> L Return Receipt Showing m Whom. <br /> Data and Addressee's Address <br /> O <br /> TOTAL Ppstage F <br /> C &Fees 9 <br /> O Postmark or Dale <br /> 00 <br /> M <br /> r E <br /> 0 <br /> LL <br /> y <br /> (L <br /> n. <br /> SENDER: <br /> y • Complete items 1 and/or 2 for additional services. also WISh to reC81VB the <br /> ® • Complete items 3,and as It b. following services Ifor an extra m <br /> ` • Print your name and address on the reverse of this form so that we can fee): <br /> N return this card to you. `y <br /> N • Attach this form to the front of the mailpiece,or on the back if space 1. ❑ Addressee's Address y <br /> does not permit. <br /> L • Write"Return Receipt Requested"on the mailpiece below the article number. 2. ❑ Restricted Delivery 1 <br /> •' •'The Refund Receipt will show to whom the article was delivered and the date V <br /> delivered. Consult postmaster for fee. v <br /> m 3. Article Addressed to: 4a. Article Number <br /> 0 .or <br /> U/ Go <br /> CL 4b. Service Type cc <br /> E0❑ Registered ❑ Insured ` <br /> y / -t6o ,.B Certified El OD y <br /> y 0 A pzC <br /> El Express Mail [Return Receipt for o <br /> / Merchandise <br /> /,3.36 7. Date of eliv ry w <br /> o <br /> Z <br /> Signatur a <br /> S. Addressee's Address (Only if requested Y <br /> A se 1 <br /> and fee is paid) at <br /> F- <br /> CC F <br /> 6. gnature (Agent)) <br /> m 716S DOMESTIC RETURN RECEIPT <br />