qqz.(0--1/74q0 <br /> F. date / / / / L NO. 340977 <br /> .�.y recei� m CC2 I L) ( $36 CO <br /> dollars <br /> for payment of <br /> V 159ash md <br /> O order oney O card creit O check # <br /> amount due !CO <br /> amount paid d 0 from ' ) to <br /> balance Signature <br /> . DC250IWS <br />