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STATyNLT~Ti QF CLAW. BY µPA/~ /Qyid `~l~rvhctc~/
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The ~ndersigneri hersby presents for piing again the above estate tnis statemerai; of oiatiu: ~~-
I. The bWsie for +,12e claim is rl.~~l i r_Gt,~i Oy7 di-s~J Psox~l
.'. Tne SC^2a1 aeCU:l±y Or *„^.:: ldentl'RCal10r1 number Oi the Clamant 15 .J~f ~ /'7 ~ q ,R.
tee name and address ortb.e claimant a/re/ ~f'755 sou.-f-L~ ~urv~uG
/O il,(~dt UY7/D ~l3(v~5 _
and the name and address of the claimant's ettorney, iI any, are as set iarth bQlou•.
~. The amount of the claim is " l ~. /7..Sa~
t~~hich amount is nov,~ dus, cr. ii not due, will become due or, ~ (: ,,
_. The cl`.im. 'is) (is net) contir_nent or uniiquidated. If contingent ar uL;ii:ruid;i*.wd, tlzc;
nature of the Lncertain~~ is
J. TYIe Claim l:S) ('.3 nOt) °eCnreG. If SeyIlTOG., l;ne SeCL'z`tL}' :.~I1SL"'~S 0`
Under penalties C_ PeIYtTli1', I declare- that I have reed. the zoregoing, and the ia,cLS aile~eu fir`:
true, to the best of my i:nwaiedgaand belief.
Signed on ~ , ~ pLo~.
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