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date 12 - / Z-7 / j 3 No. 340976 <br /> received from /1//C(1-0 LIS- A Lr3ie C-41-7 11 g, © O <br /> /� C� dollars <br /> for pent of `� — ` x b u �� � C r^� <br /> cash money order ard O credit O check # <br /> c <br /> amount due <br /> amount paid /i from to <br /> balance • :C) signatu <br /> DC250IWS <br />