MEmMo. ge MATE 2 | @ XP TION AMT. CHARGED | AMT. CREDITED BAL. DUE

JUL25-4% RogH ecco x 3.00
JUL25-44 TAX eee * 0,06 « 3S

 

 

 

 

 

 

 

 

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Form 569-A 75M
LAST BALANCE !IS AMOUNT DUE UNLESS OTHERWISE INDICATED
PLEASE RETAIN

FOR TAX RECORD