Loading...
HomeMy WebLinkAbout81-00753 .' 1:\ d.',,!" -'d. ,. -",., i'~ . .' ..,{ ." , ,;,1 :'ii:,'" :'~'~~, ,;" ;;1,_0___';',_: - ':~QI;/Z~-Y;oJ" ,';" ~~g':;,f :.:~t;il'> "" ~_~'i., -:0 ' ~< , \r~,;r;>," :':".' tr:!:. :" ','I' 1,' "~,;,)~.!.'Y\' ':'F'I{;:-:- ,-,.> ..'; .-j. fF,'-, if !~~If': f_~_=~_fR";;_- .,~k~ ".-!, ;;!; " ,..-.1, (~5" ,:I~~' ,.j' " " .. ,. 't J ~ I,; ',; " I"~ ". 1-" I. " ,-; '. "j' " " :1 " ,~ '0 .. I: i' .' , ',j . r ~ ;' " 1>,' " ;, ,;- ,- Jo . ,'.~' "I" ,: ' . . " " ,. " 'i' , : ~ " ,!' " ,)-" , ' ~ d' " !! 'ff " .n '.'1 '!, " t':,: _.~"....._p-~~ -_.......~... ITeM PIAIONAL PAOPIATV ~ Lilt oil tonglhlo ond l"t.nglhlo'lmnnolpro",,\V owned IndlVldu.IIV hv NO, Iho dKed.nl" the Ume 01 d..th. - 6Uh,,"od Morket Voluo pop.rtmont V.luoUon 10fllololUIl Onlvl - t~fiJ1fi;-.~)---- ~~.~~ '~,4~" ,~efiJ41 TOllI JOIHTIoV'OWNI\Q PAOPlfiTV- Lilt oll"olond~'.o".1 proplrlV ow".d hV tho d.,.dont wllh wllh ,n, ,91h!! potlV 0' Potll.. ..IOlnllln,"t," wllh ,10hl 0, flurv, lyorthIP.ln',lu, d., no",.. .dd,r,... .nd ,.\ollo".hlp lolhi deoed.nt of th. lolnl OW,," .I.nd Ih. d.te Ih'lnlnt oW!1.,.hIP wt. .".,ed, 'I" JJ,""', ....~.... .;f't1, ,,'IJ.~ I ~/'/."7 ~,;/ ~ /, 71 tTlM NO, -" ;1/~ Totol ITeM TAANIPIA' - Lllt.1I ,..Iond por,.n.1 properlV t"n.lorred wllhln twovo... o~ duth, NO, ~. 6ltlmot.d o.porlmont'I!,lu.Uon MarkolValua '.'. ,.IOfflclol UIO onlvl ;V{~ rotal Llllell 101, d'P?,lthO~" ,.gll\l"d In ,Ih, docodani'. nam., or ,olntlv with, or 0' an .gllnt or dOP,U';' of8nothor, or In d~od.nl"ln~IYldu.1 nO,n" With rlght'oi' 000,,'01 .g.nl or !i.PuW, InolUd. tho n,me .nd odd""ollh. honk or olh,r In.tlIU\lon v.l\oto tho ..I. dopo.11 bo~ 1l100.I.d, th. n,,,,ololln WIlloh Ih. bll~ II 1'911t",d Ind th, "lIllon.hlp ollh,lolnl hold.rslo Ihod..ond.nt. Nom. .nd Addr... of Blnk 0' Olher InhllUllon "In yihlchPlo.d'nt Mllntelnldl 8<\f.,O,p..1I ~o~ e(~4..(tt~'1 Nlm. or N.",,, In Which SII. oopola Bo~ I. 1'I0gl.'tor.d f\".lIon,~IP of J.lnt 119Id.,\.\0,pmdont - NOnl You mov o~P.dlt.lho'prooo..lng,ol Ihl. r.lurn bV fIl'lnoWllh II ';nd ,.. p.tt of Ih. tllurn,l.uor,'ro!il fln.nDI.lln.Ututl.nl or 1110ttg~. hol~.tl. D.rtlfvlng to omounlt on dipo.1t o,o'W!1od bV \ho d,Ded.nt.. 01 tho dote 0,1 dooth, BUDIt lottors mull bo Ilgnedbv 0 toIponllbl. ollID" ~f tho,flnanc'ol ,In,UMIDn or I11lIr\Qige holdor Ind Indlcllo o!..,IV omoun\l of Inlnclpol Ohd Inlord!t In lit. dODodont'. ..oount 01 tho deto,of d..th ond Ihe typo of ""DDunt, "oD~nt nunlb.. ond Ihe l'ODt nom. Dr nomoI In \\11loh Iho ..count II ..gl!tared, i .. . ... ~,': U , , , , , , , ; I', I \ i I \ \ I , ~ \ , \ i 1 ~ I ~(p Oulll Kay ACllUUllt ri NATIONAl. CI:NTRAI. DANK 9,8, NO, ..\'~J.~~g:::tj\i'/\\ ACCT, NO,6l,",!I7.00~65. NAMa .,.Vlll'!L~111 Wl~.1\1u", .~..,...~. ......".., ,~JEg H \., .~guIIUI'J}I)I_M.nQ\)1,\1.1!9_tP.~~tl.l1710,'~'r:......._~.~' ~, . ,;J:> , .!' \ \ ..... _. '. '. ,_ ,,' t _. .._,: ... -- .r'_'_"'_~'--"" . I ! ----~-,,....,-~ ~L._..._.-__:_ ,/.,~".....".~".H__", 'N, ",',. , ,\ . PepoSltor's Neme en~ MOo""t N~mber ' Appear on 111,I~e fr."nt Cover tJAH WI1tHI,."W....'. -=::t~~..-'- 1I1_pCJtjlt _. . IN,._"I'!.!. IlAl."'ln 1M""'I. ~ '3 2-25"81 i"-IlI~SI 8951 ,\ 134'; r. U 7 R - U 10 It t" 234c; , '1 111,u"dl1lo"n UA nl Am' Chill\11I ul Addrttu 13 H 11', 1\1 t7 IK - "IU 20 . .,0',ll'M""-'_ .~'.. -,t,'. "', u".- .~., -""""'N\.'~' ..,~..t-._.. .;::: !" I ;~r..' ',.\.., " 1'\ .. .. .. ' ' , 'A ' r... ." .,''''', L'/ ,'~ (tJ \ f'-' .'. ... ';'f"'_~_, ,.'1 ,.-, -!~'f'f .,..(~ .';..: .~,.. '--j <. '- ,,~:,~ '...,.... ~ ',.,_;,Ii.;-,-:" ;...'_~_ ._,.....,-.t';,,;- - ;, l'\'l-~! "L~tt~".'-,..-- i' ~l"'-' ...-, . - ~',; . .,.'- ..... ,. ~ '." "'1~ Ul :.nl au 1ttATlPNAL ClNTRAL BANK I ~, ~.'~ -~ , , , , , '. I.. \ ' ' I' . , , . .. I I , I , I "4 I. ' I i; . , , I i , , I , , , I \i. . -, --,. .-1-'- ")' I "i. . -~I:Ail+' ,- _ ..._ ~-,'" ~~ ' , 'r .; .~ '" ,__ f-. . ..... ..- ". -1--- ---; .-- ::::::. =~=-- --= - ~!l_u I 1 c~... ,_~. _. .-f ...-" ..., - .+-- ..Yo! r. ~nn II Uk l. , ' _.11 m "t. ~Il.n Dr. HGchantcsbura. PA 170S5 1M ~Cc:q1lH r WITH : CONES I f.k.....fIV..,....DuUNI ,...,"',.~..."...... - ""j '"I'" tHiM.UI.t!I'r "tilth r ;=":,.iSE!l!J,1I " .;, .,;".. -~'lI:JIlll'ilI'iOA~ - - "" IItIIiiI.MitI l5s~r'l~l-<?~'Jl"'l~ I CCNEI ~"""'~-~iQ;"""t., N_..tN.w...~ ~~f~tQ~~~NY , _11," 1'hl, lot., I~ fl,crtP',lJ lI,lll!' 1111 'l'I"'_lll~ _ 1I11-1U;\lI...UbjtH IU Iht Ih' 11.;IW~ III 111~ " II".." ""'Htn pnlll", Mtd"CII*,"" "lilt! u 1111_ Il'ltUll \Hlllrll~I. _ _ _ n ....."m..;,ht l:-A;;'i~';Il'Jt"Uf 1!l1I1I'''" "'llh411ll'II Ytllhllllllllrlltllllllllfh \11.1111" 11f"1~ All" ,~~l~L . ""llIfr WI'H"~W4U A,~"Q'n' I, "~~"1;I', Mlt", II~" '"" II. ~' ....... 7\7J; '"1 'I ~ , ' , .~~HO' .... ~'+ I ---- M:7 I \ \ ,.......~,'-, '~I -",_.-.,,,,. , 1\ ,: Ij t. ., 8In(l.1910' .&J,~~Jfun'tul .lium, Jut. . 10\'1) L, My,,,I. luptrvl,or 'B71l, MAIN 8TRUT MliOHANIOGBURO, PA; 17066 (7' 71 roe.a421 'ROIERT J, WOLP Atsoclet. IIRIO L, HO~LINtlIlR Anocle'e MIOHAeL J, MALPIl;tZ1 A..oclete rO~~~'" '~~~\'!:~u..I\,>,,"\).... \I\Cl" POR TH II f'UNllRAL OF .'..~:xa., ~f1\r.-\ \.\\,~~~a- ~u./'t..~. \\~ 18J.L itemized AOGGunt On Inside paga ,;:' , '. :., ;. ,. , "" " I', . ;~ '\ :' I. 1 . \ '. \, . \ " .~~ _\.:, T ~ ~ " .' i .. ., f.; ~ 1. t',.-, ,.' "; "'v<~l , 't".,' ,'~ , r"~"'\ -" ~; " ~' . . "- ~. ., . ,'~ , , I,:. '.. ., ,', , ; ~ ,t, ) i , t-", \ , tJ f( " :, ~ ~~ : .. 1. 'U il ~ W j; .... , , , ,," .' , '~',,', - , . .-~-i'> .-"- ::, . '_ ,r~ ,', - i"';- - ',',' , :' ,:,{~~ ",j ., >:~( .~-.: , , '",...9 , .. :'; - :~-~ ::",:: , ',';,," ,_ I, t:' . ,~,- , ,'>~ . ,.\- <, ... ~ J N .! ~ 1 . ffi' i I~ m = II ~, ; ~I I if! i ; II, .' . ell . = ~I ~ ~~ i II II 'g I I I .. ........ ~~8~' J ~~ 7: .,., <: R ~'; '\ ., ~ f ~ ~ Ii'" I',] "':~' ~ ~ i ~. ~,' :~~ ". .~ . m ';~' ~ I \;: ,~t ~q 1 , :I] ,I i ~ " j' ~i ... Ie : I . ,f ~ n J If;H ' , ,,]~ ','J i~~~~' ! ~ & cl rtl <J '~ == 5l ~~ i ~ ~ ~ /\ a' .., ..,-! .,.. t. '~ ';\. ., to 1 J .. 11' " IILt'~;1 h If' HIt! i r .. ~IHh ' ~hHmhI' Id1 ,~ " ~.d <J .,J J .., . ,~, ~ .d <J .,; ~ .., ...d ,".... ,.j ... ~ i j I ~ .d .) ~ -' 0 s . ! 1;' Oct (J . it , ~ e i ~ij ~l ~ .. l' l j ~, .' ] I il ,f I ~ iH~" I H!~! L ~ I., ~ .( iii r..J ~, ~ I ~ 0: ct 1 I ~ .. t ..i I' '~ ~ t 8 ! .' 'l!.. "'i' 2"12' _Ql ~ g ,~ i ~ ~ ,/. . f. .. ..... I' '~;~^I~~;S'I~;'~~~;fi;;~;~-C-H~~~R~JY V ALLEY'-M,-e, MORIAI"S,"~INC~' 't:~~~~'(:;;,':n;'~II~:>3IJ~~~::::~ACf"~~~~-J' . 13ETWEHN CHIRRY VALI.IY, New YORK 13320 '~JMAII ON WOHKilll~~' 264 7 . , 607. 264.1201 Jrunr~B MAnKan ------- I - J t'~l I ,\, c', 'I.' i j " , 2'10' "'f."") l /0 AND ,-f,.JLl,4-[' .~~_..\.AL ...... ,~.,.J.i._, '___, ,---:....___~._..___ ..~...._._._.rlloNu '. .L, .L=- -,..,-C.!.,..4 . _ .,.-:-....... :1" " /JJl.r'~' . .2' ,..,... ,;J..;J.. .,. , ' ) ) (', .,... jJt l,',' ,'''.. ...____~,-H---', - ,L_./f .'lL II, _.__..____OOl/NTY .. ~ i1, Z' ..J..,.._.r--..- , " J.g. _..~} .~,~.. - , ..' ...~....______ . t'c" '),I AJ . . . J '/'1':'/._ n ~ B TAX n^lUZ__.__'i '"'' '"1 "ONeIOI:"A1iO~ I,",,~.,.!un MH~~ONtil1kn ~~nlnmuv ~M ',hl,io, TO fU"~,IOII Ilia I'O~,oWINa WOI~, TO Will blONl!MItIT PIU. ON'TOP..,_~_...____._X_~____,X """,'F'"+<',; ,< },,' ",-- ";,,.., -.. ".~ ""','N..t-""_'.,~,I~.:;,'_,,, - "~""""","'n"'" .-.,j_ __..,'.I'INIBII_.._.________~-'--'-_...- ,-"..........__.....'.s'<........ "',,-_.,,,,\.;Fb." ' "".".,...\.".",...........J IIA6Uc__...._.__.._......._...___X __..._...... ..___ x...__~._.._.__I'INlaIL...._.___.._......._..__~ .-. ._w..m_m.._.......~___ ""AAKER8 _._....:..-... 0 BUVUL 0 ooua~u Alivn~ ~~L. al.ANT 0 OU~, Il~ANT 0 F~UBH .. I ') ;l '"Z ' Q,:=:O ___x_~J!2~(.,~._X._. /. t.. .__FINISH._ ,1:~, --'l.?U';",~_._- All-a.. DAAIi__._. X __..~X...,.~_.._.__fINISIL~____,.__..._____._ ...c........m.m.__......._ TO'llI!MAOS Of ~-J.' tJ-(.f)1.~',___ ' . aAANITD.OO~OA 1.~4.Jl' ~,,'VI(i',. bE6IilN>>l)U;'~,j., J. lis ':'JJl.:J.t. flit ,;.4/ ~'l.~t.(I\IN~~rPTiii~B OHSOKDb vas 0 NO 0" POBTOc.?:::". !t.':TTIIIINQ MAOHINrl Q pUP~lom 0 BPaOIA~ 0 .,... ~ 0, fRONT V rt./(A A. L r: i rr w tI KIIE. WiPE OF WII,/N/:- . Moih~~ OF JilllIL':;>/ r<r:.vitl MffY I~ I NrJ.&' - ' WNIl' 9,/f1l1 BliCK '''...''''''-I''wll _~UJ..,,_8.Loo '"00'''''''"''''' ~.. G..!?) . ~ ;~,N- -uL'bu'- "OUNO~TION ~,u\ 1 t ~~~bl:U~~~ '~F~~~~~:~~~~6't11\kfi='.-:- ,I UWll.~;;~~~~;~-;;.F~Ra~..AI~ .~ OOANP\ rOSTB --:::....-..J _ q Y oHellRY V"~~lV "'lMO,RI"~S,INO', Tl1AT1 WILL rAY TO BAlD CHaRAYVA~~"lY "'U"'OAI,,~&,INQ,,' FUL~ pAlott ...!:t~,. OOMPLttTB TIll! UA~ANOE ,OUD ONOIi~IVUAY, 6AID OHlRAY Y"~~IY MIMOAIA~8, INe" TO AIT^IN llT~a TO 01i~061T -!:I.. ~ r ",. WITH OAbHA Tlit> A,noVE aruolFmb WClAK Utp;I~PAID IN FUl.l. , . mCUlliP THIO.!lUOAY OP_~"I &.'~ ," ~o .~1__:_ , UA!.^NOE oua, P _ ON OE~IVDRY ?~~:~J.f.f.-l.f...!f. (~L.i '__ --.Lk~ /;1<.1 j ..J _~.-.._. " ~ ~Ho"", ~'"ulfc:mll~'" .. " 1;11, NO, ' , I COf<l'I'l' PORU IolUb' on lIi8TALl.l'll by CBlolal.11Y OI'PICIAts, tululU'- HNAt..PMU COMPI,DTICJHIB,NOr INCLUDr;D IN HU9 onDlill nHifUi L nr: ^'OIiA.AOtl roilAtmlllONM.'I.'TH:lfIUO Mlnn O'LlVln'l', Au OlmtHfL8UUJtOY 10 Ptt.Mbtx~(JA9IONtb 11'1' ^COUJllNl~_,fHnIKED. rmf:8'OI\ cAuSlll, I1th'oND QUit COtnnQL. A.R II IllllVltll! TO nun CU8TOMIlrtowrl WI~l. _tlANlll.[ 'lia ARAANcWMIHH8 WlTtl your, cf,Mrbtthv ron Hit! IN81M-ltlION Ot A tOU'fATlON TO UUf1I'^,t1nn IitHllH\ youn MEMo. ~~~~'I,~~~Wd,U~f,~HIJ'I\WI~VN:'~~lt'~~ ~~Vtr:d~~~~l~~f'oNI~~I~ (fg~~h~\lg~ ~~ U6'A~g~~~t."bbri~L U IJnIVliRt10 TO' Wi CllMlHunv,U'_ flHi fOUHI1Al10N 18 NOf Cttt:t\RY VAl-LU MIMORIAU, INO. wonr. euAll lit C(JNSIOcr'~O, COMl'LIiTtD UPON tllillvtRY OF MIHAonlAL Hi CI!MflTl!flV ANO FINAL PAvMI!Nt In Dun AT TIlAf TIME NO l:(lNlhACT on iJUHlAl ^fH1l'I:MIHH, on j'lwl.\mtL OlfrUlIN<l I-nOM HIM Wnlllt:N ANO Ptm~tto ItEA'IN Wn,L un 1H1COONIlllU U't' CHIRRY VALUV .....ORIAU, INC. lUnMa. 11'.... "EA MOtiTI1116...PER ^NNUMIINTUREST AFTEn 39 DAYS, CUf,TOMIR COpy Jl!'t 1&'11 ~~. ,:I\I'III\L DUll (,1111"', l'II~I'Ii;YIS^"II^ III.LlL BIIII lillll'!!(,- !HWl!L IIMlil;hu'\;jl'l\ 'r ltilil!IIHlll\l1i tOt I i 11'hhIHI,'<-j ~ ~ E~~' cr VU"A 'IH f II fPl, ~LhE;l .fHrt Vl: tI,.. IIAIH,r.U.U,H. IIA ['ill ,vllii it (I!' 1I ''''!! ',111\11- j, ,,,' , IO::r'~ij(I'l U'\ ." .,\''': EAST f't~lji. I"r~ ':IIlI~ 13 (l/!\l~ ~~""""~ U, 1 I I I I I I I , . iv'~"i~I;W:i!il!~~!aMII', ~"il~~1g t~~;1 t t~'" lIrfl ~! II~X MUM IENlFlt OF ~25Q,QOO is $01/ .70 . ,. , IWM^"~1l I I ! , \~ ,~ J :l Jo .~ 2 a ',' ,~: -' ','. ..," i ,;,' '. ~ , . '~- .. . .. . , , , '. . iI'~. '; '. ;~' '~'<:'8_ .-~ ','-, ,',_.' > '(I'~41 ,,~. - ~.': ,.~-", . '. ... - ,<-. ;., ;~-, ' :;~" - , i: ~ "I ':. - ::.:> + + "r' IXI'I iI\jAII, ill (" # 11 M/\.liJlI MldJliAI III 111 III', t, :a.. ~fJ~(,t~,'i'" """'"" 038496 I"~:'I L'Kl't' 'Vlol(A \ (.I,llll/,q II/ 111l1.WIII 1}~~}f~I~,~t!I?~ _ -j 1-/'YI.llljl pHil I !P.81:1111il'l,\/OIl i lltl~/1;1 flllllihl! ft,lld Illllllt ,nlt:illhi(I,;P iihl>WIl il!jllY'1I Wll,l!t\ Wqilllllllj IIlt'!ql'VPlll fnlllll ;1 Ii; pdl" I dli II' I '1-; Ii:,; '; .;'.'; j;, q;; , ;!!;,lii\'1 1,.1'111,1 II, II) O,nq , .111 W~.t)'" I 1 Ol^' i"IIOlHU' r~XPII~HHj I,\lllh Ullwl 1111j\jIIIlH~I' L.1!!i1l CUIIAVI',EIH ~jI"I)'~'U('i'~" >< \ . - :) 'i ,fl. ,._u_I9'!(l((\M9YEL9JU'~,IIrM!;!~.I', ., ~'- ':~' " . j '. . ,f( '{i , " +u Capital Blue Cross Pennsylvania Slue Shield 100 Pin. !il,..t, HnrlhhulU. P.llntylvllMh, 1110t (JIll H~.6000 33Ji$IE -41,1 3 f~ MAJOR MI:DICAL BENEflTSSUMMARY ,- ' i ._- - __ _ I ,IM~C)RUNTI Ret<lhl Ihlt Bonofll $lIm11lCHV Fotm fo, huo",n Tn> Nura," if nulled. Oriyln~1 bill. 0, rotelph cannol, b. ,.Iurn,d, PAl~ , 0......., '~p,e,."RIQ 0 'COVfRliD , Q'PIT~t. aCTOR URII PRUIJ , tlT"'5" 'IIUON peNTA'" "NI' . PAHrNt5 ~IAMI. V Wll.KII O,,,U"" 1'0 04l-1&-11 $, OMO\H'I'IO ClAIM NO """ ,,,.UJloq,9,,n I''lihl' lUlU.... UlN'~At1 Ntl (,,,Ai 1'1,"',1', 010$',9,9,00 iV,'>II't'llIIl1 OW,UI.....07 ""lim'A.l hmnt\ .ll";\!' ~ ; <)!IJI,IJI . 1, , " $ $ .0.00. II.U '0.0'0 :SO.OO 11.16 '0,00 TOT AlS UI." UI.I', $ '41.00$ ~M" , $, $ ...n $ II~~ [IrPUCIIRIE lOTAl SUPS(:~IRE,R PAYS 10% OF COluMN ~ 5UB~(RIRf.R PAYS '.b OF cQIUMN a "'AJOR MWICAI RENHIlS PIAN PAYS,- ~ ,YOU HAVIIUTUI'UD ,... - ,- " -- .. - ", , 1 f. CHVC.K. ,. Uo.oo 01'" 'HIU~UIRIO Uu D!PUCTU~ $ usn I ,).to' ,~ 'f 'fJO" ~1 tl~..~f I . c ;, ,''\ , , " . ~ !i 11 " , IT , ill . '~ , ,J .. , c. -. ,. , j~: ":! , I~' , '. 'J" , . . 11 , ,f , " :.:. " ~ " tJ , "" , ~.~ , " ~\ ';: , " ,~ " J i " ,I.', l-, , \\ .' ,,'; .' ,:,,;_,..;t : ~\~\,,'~:~ . ,-~- -f~ " ~ i ~, ..;- - ~ .-' .. ; '.;~ .... ':....' ;"'1 . .' ~, I,; i, ,i ) . , " C"e" Y~~~!A.NTI Hoicalrl.thl. n~lIuli' ~UI"matV F~rm fllr IIICUI". TelM Rllllo,," if ,,,,,,ct.,1. OIlUIIlIOII,ill. or ,",,,Ipl' '(II,lIIot "" (u'turned, 0.U3~,Q~00 ,,', ",,'u9IIIg,9.U 0~,UUn6-011 i\p,1t nUl' !'HII;,i', Ili!l\(; 'dlll' ,q l,lttl'l\I' ((-'i",,"I' rUIIIMI.'ft \," '\ \~ ' ',. '-" . I '.U,~' .-r~, Capital 61uu Crois . Pennsylv~nla Blue ShiQld ...-"" 111\1 lilt'" l.lilp'lllqtjhht;'H. 1"'IIlHyIYUIIHI 1/1(11 ( 11/11"~I-bOO(i MAJOR' MEDICAL BENEFITS SUMMARY ?~W' U-lI-81 P~HIOP covmo l'Allll-'I''1HAMI 'r'iHJ\WN(J t"'iAIM H() v WIl.KIIt Ol-U-U 10 Ul.U.81 $ -,;1,';-,\ ~ j, U.OO)( t10ltP1TAl. l)QC TOR NUt\fll! UHI,Jli UTHt:R V 18101\1 l)l!.NTAL. 1I.NI' 1I1>>.uO 111>>.00 lor ALS , GI>>.oy It;fl~l 1)I,IJUClIlUI: $ r0fAl $ !-..\!I,'.oUfIlIlH P/_'1~; a 0 % Of (()lUMN ^ :1. ; 'jyl\~i\ IO\iIU PAY'" ~I' 01- cOlUMN 1\ MAJOr_ Mt PK,\\ IH~'H IW, i'IAHI'AY~l,...~+ '!>> tt-,7 P, ~ C111;C K 1'10 NONl l'I.ltlltllAn t{Q, > $ 1O'~ .00 .00 ,00 , ,00 NPN! IIIIAI /o.MiHII~r 01' CIII'CK . YWHAVe: 8AHSI"UD, 91>>.00 OF THl! REQUtAt;D 19&1 DIDUCTIlil.!,' ~~~AaI8!E,tHI ,INC~08IDFQRM~ ' " " .." . IF ADPIUONAI;; INprOR,MUION U R~QU!8TEDl PI,.EA5E UND IT TO ua aOON. WHEN wtAlclUVI n, YOUR'CI,.AIM Wl\i.l.' 81 n,pUNUPIRED. po NOT CQNIlOIRTHI UNPAID PCRTtON A ";INAL. . UItNlA~ AT THlI ,TIMEt ... ' ',' . I1DwIViR! H A,NY P,ART Opr youR CloAIM HAallUN PINUP AND YOVprU~ THAT IT It , , UNJl,lltT1I'UDI, YQU loIAV APPItAI,. AV WRtTlt:/G TO CAPnA~"l.UI CRCaa wn~lNU PAVS ,01'" THlS NoTtCI PATE. STAT! WHV VOU nUNK VOVRCI.AIM 8HQVl.PNQT t1AV,e: ~UN OINIID. lNUL.Uol ANY INFQRMAHONYQUTHINI< HAl A AItARtNG ON YOUR ,C'-'AlM, Pl.usa IN~L.UDI YOUR CONTRAcT NUM~IRe THANK YlJU. ' '\o4A '<' ,,". '~:)~ .',,,'.,'. , . ~~" .'<~~;' ~j .'. ),-~_: - '-~{:; , ~-" ' '. ,..';,. .', \;. ", :~::'.. _:~' \, .,-'.','-.'~'. \~. ',:; ~;.~.:' .;-.'J.,. ~. -;; ~~~i~': :'~~ -. ~ ~ ,.', ... :"',;~'<>' ;;~. .: . .~,~, ' '/l."~:~~',:" ~::.::~.': .~t~c.-, :~,;. '.' ' .,:,~.\:,}-:.:;- ,::: :: ~ ,~~<: .'>,.'~" ~:;; .,'i(,' -;'~ " , .~ . '.. .' ,r ,'i ., . .- , \.",-"'."".,', .~~: . '<,':.> < .. ",'" .' " "'- .~. ' ; .. i . l '. ',' "'S" 'c,< >;:~~ ,;' ,~.~, ... , ~ .. ' ""~' ,:~m. "::~,:' >:~' . . ;,....... ,j ,l . ,{; t ',' , :4"' )0.00 10. 0 O~ .00$ eOO .$ .00$ $ '. '. . .LtIJ'QJltM ~ION Tu Inluroprol,or Cllllllt 10 your oouounl. II", n/lfno ollila "01010 and fll" nUo'bur IlIould uo oloorly prlnl' od 00 1110 ohouk 01 monoy oldor, Tille 018011"101\1 la Inndo 11\ ouuordll""" willi Soollon 708 01 Iho Il\horllal\Oo and Ealolo To~ Aot of , 801 In P.$, 9 2480.706), To Ihv o~lont Ihal Inllorllonoo II~ Ie paid wllllln Il1roo (31 1\\001111, ollor 1110 doall' at 1110 dvoodool, 0 dl.couol.ofllvo (6) poroonll8 IlIowotll72 P,B, 9 2466.7161, lI\horltaocu To~, olhor Ihol\\II. on 0 IIl1uro 100oroat, la duo 01 Ihe dale of IlIe dloedonl'l dOOlh 'el1d booon\e.' dollooUOnl at Ihoo.plrR\lon 01 nino 19) O1on\lla ofler Iho <looodoOl'a dOalh (72 P,S, 9 2486.1111, Il1herlllnoll rex on .a 1\IIUro 11110r.al 18 pOYllule wilhin Ihroe (31 monlhl .1I0r Iho tral1sfor lokea ellool 10 po..onloo lmd . enJoymonl ond II dollnquunllhoroollor (72 P,S, 9 24BO,7121, Ooloul.IO Inloreet Irom Iho dollno\lonl dOlO .hoWn on Iho fooo of Ihla lorm It) Ihe dolO of OOluol poymonl uolng Iho following Inloroalloble, ...""'l,..,....---.........---.. .......-- *- -.......--..--... .......... -_....~...... _..............~.... - - ---... ......... ~'-_....._'.....",..- -... -- - ..,...'".- 1 monlh ,006 4 monlho ,020 7 monlho ,036 10 mOl1lhl ,Q60 2 monlhs ,010 6 monlll' ,020 B montha ,040 I I month. ,066 3 mooth. ,016 6 monlho ,030 9 mor1\he ,046 12 monlh. ,060 I dil'l ,0001 7 I I dove ,OO1B6 ! 21 d.ye ,003B2 2 dOYI ,00034 I 2 doyo ,00203 22 days ,00368 3 day~ ,00061 13 cloya ,oono 23 doye ,00366 4 dlYI ,0006B I 4 ,lave ,00237 24 daYI :00403 6 dol" .00086 15 clayo ,00250 2B days ,00420 6 doye ,00'01 16 dove ,00267 26 days ,00437 7 deya ,0011 0 17 cll\VS ,002a4 27 daYI ,00494 edaya ,00136 1 BdOvs ,00301 20 doys ,00471 8dsy, ,00162 19 cloyD ,00310 29 doy. ,0040e 10 daya ,00169 20 cloYI ,00335 30 cloys ,006.00 _", _ .......___....__ _...........__..._..~__._ _..__..._ _.__ ~...._t.,.... -....... ..-.- ....-......,---- - ----....---..-- ---..... Any parII' In Intor081, Inuhldlng Iha Cornll1onwool\ll oml tho pO'80nol reproeonlu\lvn, not entlefled with tha 08lnsarnanl may oulnol Ihoroto I....llh\l\ sl>ty 1801 dovs IlfIM rooolpt of thlo Nolloo ne provldod, by Soollon 1001 ollho lnho'II0110e end Hatalo Ta. Aot of 1951112 PS, 9 24Bp. )OO\), Make ohock or rnonBV order \layablo to: "Ragletlir of Wj!ls, Agent" . Mall to tho addfllsa lIijtud bolow: