RE
    CE ~V
    ED
    CLERK’S OFFICE
    ORIGINAL
    .JAN2I2OIJ5
    STATE OF ILLiNOIS
    Pollution
    Control Board
    SEN DEfl
    COMPLETE THIS SECTION
    COMPLETE THIS SECTION ON DELIVERY
    •
    Complete items
    1,
    2, and 3. Also complete
    item
    4
    if Restricted
    Delivery is desired.
    •
    Print your name and
    address on the
    reverse
    so that we
    can
    return the card to you.
    •
    Attach this card to the
    back of the mailpiece,
    or on the front if space permits.
    1.
    Article
    Addressed
    to:
    1/6/05
    E.M.
    AC 2004—084
    Christine
    C.
    Zeman
    Hodge Dwyer Zeman
    3150 Roland Avenue
    P.O. Box 5776
    Springfield,
    IL 62705—5776
    2.
    Article Number
    (Transfer from service label)
    A.
    Signature
    ~-7:~~’
    ~
    0
    Agent
    X
    0
    Addressee
    B.
    Reç~ived
    by
    (Printed
    Name)
    C.
    Date of Delivery
    /2r~
    L~-e~
    /T/~~
    D.
    Is delivery address different from
    item 1?
    0
    Yes
    If
    YES, enter delivery address below:
    0
    No
    3.
    Sprvice Type
    ,~.CertifiedMail
    0
    Express Mail
    o
    Registered
    0
    Return
    Receipt for Merchandise
    o
    Insured Mail
    0
    C.O.D.
    4.
    Restricted
    Delivery?
    (Extra Fee)
    0
    Yes
    —
    7004
    0750
    0004 3960 2243
    PS Form
    3811,
    February 2004
    Domestic Return
    Receipt
    1 02595-02-M-1540

    Back to top