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STANDAf~D FORM FORM
~~~~9 ~ C~' NP~M~~ Mw•MM M id~~ O~d~ s~ ia~.ry ~ 11~ ~wr .I 1iwY~
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SCIIEDUt.E •A• SECUttITY UST ~ 6rand~ /Wdnsi Strq~
O~scrib~ wn b~? oolo~ and sqN:
Abbe~tviaRians - Mod.. Trad.. Col Medi Fr. P. -
Describe sppliance by s{se snd brsnd. Verbsl Ust3
~ [j Yes No
~ Sofss i Style Ty
E Color Size (.k,., B~and
i ~ Lrounge Style . T/
~ 0 Chairs ~ Color Site r- Brand
o Occ. ~ry
` aC Chain • Color Size Brand
i ~ Stereo
~ V Tsbles i S le v~ T Brand
i Z Cotfee u~ Room Air
Tsble~ # S le C) Condltianers ; Si:e Brsr~d
; ~ Rugs . z Range .
+ J Size Color ~ Brsnd '
i G~~ - Refrigerator
Si:e Color ~ Brand
; ~ ~mPs # ~ Dishwasher ;
T Brand
! Dinette $et < Freezer Y,,._ - ~
~ I"` Z # Pieces ~tCF S le Brand
p W E~ Washer ~
~ ~ Tables ~ 5 le Brand
t
o Chafrs # Style ~ pryer s
~ W ~ Color Brand t
~ o F- Sofs Styte Sewing Machine ;
~ 1~ Color g~~
~ Desk Vawum ~
~ Z T Brand Eil 0~''
Power ~Type ~
~ ~ ~ Lswn Ailower ~ Brand
~ Suite p~a~
; # Pleces S le W T ` Brand
i N Suite Organ ~
~ # Pieces 5 le t T Brand
~ ~ Suite
~ Ma
jor .
~ ~ Weces 5 ~e Power Taots
~ ~ Suite
~ i Pieces St le W ~
~ ~ Rugs or Size v ~
~ G ts ~ Color N
~ i °D Chairs ! ~
j Color ,
Lamps ;
~ T
When and Where was furniture purchased ~ ~~qC"( O c/~ t(,~rr~.~~.t ~s~ S ~ g() ,
Custamer's estimate of value
~ With what company is the turniture insured: Name
Pc~l ~ Address:
~ Schadule •M Security A dsted the day of , 19 ~
Origf No
~ ~7 ~ a,.,,,..~~a. ~et~r~w.
(Date) (Sa~sl) ~
a ~ ~'LliLtG' /~-Gc~'»~~y
(Wi tne s s ) (Date) (Sea1) ; ~