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M SENUER: . I also wish to receive the <br /> ■Complete items 1 and/or 2 for additional services. <br /> rn ■Complete items 3,4a,and 4b. following services(for an <br /> ■Print your name and address on the reverse of this form so that we can return this extra fee): <br /> card toyou. <br /> d ■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address <br /> Z <br /> d ■Write'Refum Receipt Requested'on the mailpiece below the article number.' 2. ❑ Restricted Delivery 0 <br /> ■The-Return Receipt will show to whom the article was delivered and the date a <br /> delivered. Consult postmaster for fee. <br /> 3.Article Addressed to: 4a.Article Number m <br /> 4b.Service Type <br /> ]HENRY BENJAMIN ' <br /> ❑ Registered LTJ OCertified � <br /> 1412 CHRISTIANSEN DRIVE ❑ Express Mail ❑ insured <br /> MODESTO CA 95355 ❑ Retum Receipt for Merchandise [3 COD <br /> ' <br /> 7.Date of Deliveryt <br /> ' z <br /> 5.Received By: (Print Name) 8.Addressee's Address(Only if requested <br /> and fee Is paid) <br /> oSignatur i (A ssee or Agent) <br /> a <br /> Form 11, December 1994 102595-97-13-0179 Domestic Return Receipt <br />