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<br />?.O. BOX 7371 • SALEM, OREGON 97303 •(503) 581-~683
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<br /> i .60¢ LB i DECLARED
<br />~*'lARION 4QUN7`1' ; ; 588--7915 ~ flERARTI E VALUE CERTIFICATED
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<br />I AM OWNER OF PROPERTY DESCRIBED. I Dlp NOT CAUSE OR CONTRIBUTE 70 bAMAGE SET FOR!TH OR HEREIN. ALL STATEMENTS MADE IN THIS
<br />STATEMENT OF CLAIM AND ANY ATTACHED Dp~ CUMENTS ARE TRUE AND CORRECT TO THE BEST OP MY KNOWLEDGE AND BELIEF, AND CONSTITUTE
<br />MY COMPLETE AND ENTIRE CLAIM. NO MATERIAL INFORMATION HAS BEEN WITHHELD.
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<br />REGULATIONS REQUIRE THAT ANY CLAIM FC~R LOSS, DAMAGE OR DELAY MUST BE SUBMITTED IN WRITING BY CLAIMANT WITHIN NINE (9) MONTHS
<br />FROM DATE OF DELIVERY. CARRIER MAY DE~LINE SETTLEMENT UNTIL ALL CHARGES ARE PAID. ~ .,.,, r
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<br />. #215-CA (5-90)
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