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~ ~ ~ i , ~ ~ •.•i5 STATEMENi ~t prEV:r ~-d . 3 t:l. .q ff cr • : r.~ . tv.~^ , t . e .d-: , 3 Ms• .r. y :r~re i 1 c.nyl: [ - _ ~ - - ~ - - . . . _ . _ _ . . _ . _ . . _ . _ _ . . . . - . . _ . , R pebip(sl ~Lott N~xne F:: s, .:cd ndti .ss.^~~ 2 Src,. _d ?~.s ~~i, :rd nad•c .~..s. F,- f~i..1q ,~fi.c~r ,O~.e. T~me, h~:cbrr. ~-~nd f.~r r~ce) ; ~ ~Q.~IAM~ ~ ~Q~a~ :~/~N~ly CD~+.i~KBr ( //i~4,~.c6 J0'?i~C~ EO ~MCqB~ ~ F ~ / 7G 3 A/. /3 - . T.~c. of t~i e. c~ 336~ r r ~~~~R t~iil o~o s: Fe~~•~ ~ f~wY Ja7 CIER[ CiR 1~ , ~ ~'t: ~e.~e~ F(. 3.~~1~ ~ ;~s . ~FCoRO ~~~~i~o~ . _ _ 1-fi. ~e•ee - F!----33~su ` ~ _ _ - d 'his s!a'erne~t refen !o or q.r.a/i 'f,ncnc.nq .,t ..e*~.err _~.ea•:r:g "rl!e N-v__ - - - - ~ ~ ~ ~ ~ . ~ f:!ed w~$i J~ ~tIC/~. l.u ------Dote f.led_- 7'ZJ_ I~ ~----~--__19---` . ~ _ --'...c:~t~nx:tL.n. T~» 1.q~ .i t.nan-.ru~ s'u i••~~nt ir •++ee~ : ~e f~!ryo•na Deb cr ::~d ~.~:rnd Vs ir. to-: n~ !.ie r .l c-.t~ :~b . . _ II e{L.c'..r ~ ? " ~ n >uc. n. _ ? 7erminot+:,n- -_.,...d GW~'Y .~r,flR :{U~mC :K;.r:t{ .r•-.~5! i*,:I. me finc.~.t:^.g . . te... i:!e . ~'tr• .cc.w~~ ,-:bo.e. ~ ' ? s `rmnL Th_ src~~e! pa~r's ri h! ~~r rhe f,nartc r stur._-rn nt brar.o f~~le n„~+i>+• • S ~ ~*s i~ J 4 . fl e g s•...~n ~r.e •o 'nr vci;er:y d~unt~d ~n i~em 11 F~~e bwr. .o.s.yc. d ~ eo •F.e ois:qr.._r whose r.ors+e and address cPP^ar :n ftc . 71 ~ B ? M~endrntnl. firwn::~ S:a:emmt beorinfl ?~le n;;rrber shown obo-:e ~s o:-~~er.ded m r• ~v'h .n i~en 11. . ~ 9 ~ R~kosa. >ecwed Po~ty releoses tFt evllatera! dexribed ~n item 11 4:-,m !he i.nmcng s•~'err.~nr b~or.nq f:te r.u~.br. sh~vvn abc~r. !0 L~'Lheck if tru.. All dccumer,to.ry s!omp taxes d~.x ar~d poyabls cx ro tr_corrre d~,e ond pa~~i.'e v-rs_on• to Chuo'er 201. F. S. ho.e bren po:d - ~ - - ~ - - ~ - . _ . _ . _ . . - ~ - ~ 1L ~ ,~~RZE~ f iN~~v c~~ c. S'EQVt c Es~ ~Nc - : ~ ~~v~ .T f~~a 1 ,c~wY ~ ~er~r 335<s~ ~ Ne o~ :~dl:r~mol .heets ~w~~en~ed: ~ - ~ - - ~ r ~ . ~L/~ZG:+~ - C_!N C/ .S? ; ~ - - ~ I'4'~ ~ - ~ -f~ ~ _ _ _ - - - - - - - - # ~ ; ~ E By:_ ' _ j ~ . Sipiwfuro(s) o{ ror!ti~ (neceswry c;nty Itrm .s appticobk)-- - -S,prwevr f} of ~ecvr~ Parr~~ies) ~ ~'1' r: -~,:r~_,,, ~ - _ , _ ,~;p~;,,R:,;;.al STANDARD FORM - fORM UCC-3 . . ~ ~ App.o.eO br 10M ADMt;. _e. • ~ „ , ; 3 - . _ - ~ _ ,e~ s~ _ _ . ~ . . _ a ' ~ - ~ ~ - ~ = _ P , _ _ ~ ~