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Home My WebLink About20141159.tiffRESOLUTION RE: APPROVE SPECIAL EVENTS PERMIT AND AUTHORIZE CHAIR TO SIGN - A WOMAN'S WORK, INC. WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, A Woman's Work, Inc., presented to the Board of County Commissioners of Weld County, Colorado, an application for a Special Events Permit for the sale of malt, vinous and spirituous liquors for consumption by the drink on the premises only, and WHEREAS, said applicant has paid the sum of ONE HUNDRED DOLLARS ($100.00) to Weld County, Colorado, pursuant to the laws providing therefore in payment for a County Retail Permit for the sale of malt, vinous and spirituous liquors for consumption by the drink on the premises only, for an event scheduled for one day only on April 26, 2014, from 6:00 p.m., to 10:00 p.m., outside the corporate limits of any town or city in the County of Weld at the location described as follows: 7107 Reflection Drive, Erie, Colorado 80516, being more fully described as Reflection Bay, Lot 1; being part of Section 29, Township 2 North, Range 68 West of the 6th P.M., Weld County, Colorado WHEREAS, said applicant has also paid the sum of TWENTY-FIVE DOLLARS ($25.00) to the Colorado Department of Revenue and has exhibited a State Special Events Permit for the sale of malt, vinous and spirituous liquors for consumption by the drink on the premises only. NOW, THEREFORE, BE IT RESOLVED that the Board of County Commissioners of Weld County, Colorado, having examined said application and the other qualifications of the applicant, does hereby grant Special Events Permit Number 2014-09 to said applicant to sell malt, vinous and spirituous liquors for consumption by the drink on the premises only, only at retail at said location; and the Board does hereby authorize and direct the issuance of said permit by the Chair of the Board of County Commissioners, attested to by the Clerk to the Board of Weld County, Colorado, which permit shall be effective on April 26, 2014, from 6:00 p.m., until 10:00 p.m., providing that said place where the permitee is authorized to sell malt, vinous and spirituous liquors for consumption by the drink on the premises only, shall be conducted in strict conformity to all of the laws of the State of Colorado and the rules and regulations relating thereto, heretofore passed by the Board of County Commissioners of Weld County, Colorado, and any violations thereof shall be cause for revocation of the permit. CC: 5°61 °, A-ppl• y.as-I4 —z) AV. 4U•P-I 2014-1159 LC0022 SPECIAL EVENTS PERMIT - A WOMAN'S WORK, INC. PAGE 2 BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said application and permit. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 14th day of April, A.D., 2014. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST:thaws) % jeda our -ademacher �h , Chair Weld County Clerk to the Boa Date of signature. 4•25'I'! 2014-1159 LC0022 THIS LICENSE EXPIRES APRIL 26, 2014, AT 10:00 P.M. CCIC.C.CMCWWWWWWW-C13 ▪ �.� (9 -GC en fn CO O 'd 0 C0 Cl) O •� U C L) 9-4 ^ a v 0 b o cCIZS b E W • =o a v ; a woQ �+ `n O O %d ' J b •• 0 O v o cc! U v rV vri :- ' 4-4 0 0 a4 O O cr la tit V O— .. O 4_, O -' N � +� O O cob t U 0 cS A, ll Ct vCg v - 0 0 `)Vs 0 ^ at Cl) 0 Cl) ', ^ cl it � '' C O 0- a� o v eel NON -TRANSFERABLE. TO BE POSTED IN A CONSPICUOUS PLACE. DR 8428 (08/01/2012) COLORADO DEPARTMENT OF REVENUE 1881 PIERCE STREET, SUITE 108 LAKEWOOD, CO 80214 STATE OF COLORADO DEPARTMENT OF REVENUE VALID ONLY FOR THE ORGANIZATION AT THIS LOCATION A WOMAN'S WORK INC 7107 REFLECTION DRIVE ERIE CO 80516 Permit Number: 4800929 Event Manager: BRANDT CONNIE SPECIAL EVENTS PERMIT MALT, VINOUS AND SPIRITOUS LIQUOR VALID ONLY FOR THE FOLLOWING PERIODS EVENT 1: 04/26/2014 6 PM 10 PM EVENT 2: EVENT 3: EVENT 4: EVENT 5: This permit is issued subject to the laws of the State of Colorado and especially under the provisions of Title 12, Articles 46 or 47, CRS 1973, as amended. This permit is nontransferable and shall be conspicuously posted in the place above described. This permit is only valid during the event date(s) shown above. In testimony whereof, I have hereunto set my hand. 4/25/2014 RLE Division Director Executive Director DR 8439 (06/28/06) COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION 1375 SHERMAN STREET DENVER CO 80261 303) 205-2300 IN ORDER TO QUALIFY FOR A SPECIAL EVENTS PERMIT, YOU MUST BE NONPROFIT AND ONE OF THE FOLLOWING (See back for details.) ❑ SOCIAL ❑ ATHLETIC ® PHILANTHROPIC INSTITUTION ❑ FRATERNAL ❑ CHARTERED BRANCH, LODGE OR CHAPTER ❑ POLITICAL CANDIDATE 0 PATRIOTIC ❑ OF A NATIONAL ORGANIZATION OR SOCIETY ❑ MUNICIPALITY OWNING ARTS ❑ POLITICAL ❑ RELIGIOUS INSTITUTION FACILITIES APPLICATION FOR A SPECIAL EVENTS PERMIT Department Use Only UAB TYPE OF SPECIAL EVENT APPLICANT IS APPLYING FOR: 2110 © MALT, VINOUS AND SPIRITUOUS LIQUOR $25.00 PER DAY 2170 ❑ FERMENTED MALT BEVERAGE (3.2 Beer) $10.00 PER DAY DO NOT WRITE IN THIS SPACE LIQUOR PERMIT NUMBER 1. NAME OF APPLICANT ORGANIZATION OR POLITICAL CANDIDATE A Woman's Work, Inc. State Sales Tax Number (Required) 98-18933-0000 2. MAILING ADDRESS OF ORGANIZATION OR POLITICAL CANDIDATE (include street, city/town and ZIP) P.O. Box 817 Longmont, CO 80502 3. ADDRESS OF PLACE TO HAVE SPECIAL EVENT (include street, cityttown and ZIP) 7107 Reflection Drive Erie, CO 80516 NAME DATE OF BIRTH HOME ADDRESS (Street, City, State, ZIP) PHONE NUMBER 4. PRES./SEC'Y OF ORG. or POLITICAL CANDIDATE Sarah Schey 5. EVENT MANAGER Connie Brodt 2132 Rockspray Ct., Longmont, CO 805(303)651-6576 6. HAS APPLICANT ORGANIZATION OR POLITICAL CANDIDATE BEEN ISSUED A SPECIAL EVENT PERMIT THIS CALENDAR YEAR? I -I NO I YES HOW MANY DAYS? 7. IS PREMISES NOW LICENSED UNDER STATE LIQUOR OR BEER CODE? © NO � VES TO WHOM? 8. DOES THE APPLICANT HAVE POSSESSION OR WRITTEN PERMISSION FOR THE USE OF THE PREMISES TO BE LICENSED? Yes 0 No LIST BELOW THE EXACT DATE(S) FOR WHICH APPLICATION IS BEING MADE FOR PERMIT Date 04/26/2014 Hours From 6:00p .m. To 10:00p .m. Date Hours From To m. Date Hours From To Date Hours From To Date Hours From To I declare under penalt t - .Iltutor :t n 1• OATH OF APPLICANT r rjury in the second degree that I have read the foregoing application and all attachments thereto, and rei is true, correct nd complete to the best of my knowledge. 1 REPORT AND A ROVAL OF LOCAL LICENSING AUTHORITY (CITY OR COUNTY) he < egoing application has been examined and the premises, business conducted and character of the applicant is satisfactory, and we do report that such permit, if granted, will comply with the provisions of Tit e 12, Article 48, C.R.S., as amended. THEREFORE, THIS APPLICATION IS APPROVED. LOCAL LICENSING AUTHORITY (CITY OR COUNTY) Weld County, Colorado TITLE President 0 CITY COUNTY TITLE TELEPHONE NUMBER OF CITY/COUNTY CLERK (970) 356-4000 Ext 4225 NATURE hic3Piumci. O NOT WRITE IN THIS SPACE - FOR DEPARTMENT OF REVENUE USE ONLY Chair, Board of County Commissioners DATAPR 1 4 2014 LIABILITY INFORMATION License Account Number Liability Date State -750(999) w TOTAL (Instructions on Reverse Size) 2014-1159 SPECIAL EVENT PERMIT QUESTIONNAIRE AND AFFIDAVIT 1. What type of an event is planned (e.g., annual, quarterly, benefit, etc.)? Annual benefit 2. Explain in detail the nature of your organization, its function, and who or what benefits from its operations (attach separate sheet if necessary). A Woman's Work provides support to women in the St. Vrain Valley whose immediate financial needs cannot be met by other sources. AWW asks only that recipients perform an act of kindness in return. 3. Who or what organization will be the recipient of funds derived from this event? A Woman's Work. Funds will be used for operations and for granting purposes. 349 4. How many attendees are expected at this event? 5. Describe the premises at which this event will take place. with a walkout basement. Private residence, 1 story ranch Volunteers will ensure that only guests 6. What type of security will be provided at this event? who have purchased tickets are permitted into the event space. No other security will be used, N/A 7. How many security personnel will be on hand? Volunteers will be wearing red aprons/red suspenders 8. How will security personnel be identified? 9. If this event is being held outdoors, how will the exterior boundaries of the premises be marked (e.g., roped, fenced, etc.)? The only "outdoor" area will be an upper level covered patio, which will be used to serve food and drinks. This patio is fully enclosed by railings and therefore has a natural "marked" boundary. 10. What type of entertainment will be provided, if any, for this event? Live and silent auction. 11. What method will be used in checking identification for proper age of attendees (e.g., at the door, at the bar, etc.) and how will underage patrons be identified so as not to be served alcoholic beverages (e.g., stamp or mark on the hand, etc.) Attendees must be over the age of 21 to attend the event. Volunteers will be checking IDs at the door. M:ICTBICTBF0RMSIF0SPECIALEVENT.D0CSpecialEvent 12. How will the conduct and level of intoxication of attendees be monitored and by whom? Volunteers will be monitoring attendees to ensure that visibly intoxicated people are not served alcohol. 13. Have volunteers or members of your organization been trained in the sale/service of alcoholic beverages: If yes, what training have they received and by whom? All servers are trained by RT Magley from Twin Peaks Liquor. 14. What types of alternate beverages and food/snacks will be available? Heavy appetizers, water, tea and soda 15. Has a State Sales Tax Number been initiated by you or a member of your organization? If so, write that number in the space provided. 98-18933-0000 16. Explain how this event will be marketed describing what kinds of advertising material will be distributed and the targeted recipients of such material. This event is marketed entirely by word-of-mouth and social media, primarily Facebook and Constant Contact. 1 hereby certify, under penalty of perjury, that the information provided to the Board of County Commissior.ersNeld County contained in this affidavit is true and accurate to the best of my wledge. IC rift's Si R.01 STATE OF COLORADO COUNTY OF WELD ss ) Date 9-Aa,L4 Subscribed and sworn to before me this day of \' c -Cyr , 20 l4 Witness my hand and official seal. My commission expires: k Notary Public S MANTHA WALLACE iARY PUBLIC STA'!s E OF COLORADO NOTARY b 20124046905 ia1Y COMMISSION EXPIRES 9/12/2016 M:ICTB\CTBFORMSIFOSPECIALEVENT.DOCSpecial Event RECEIPT DATE 3.07,1 /4 NO. 87499 O cu 2 RECEIVED FROM WQma' i t, -Lk,� Obie. �mQ1U,f Cjactel.4T7 0 ADDRESS03 �1 U o o FOR 01001 r4l..A±, j ,Spx..tR Q Eu-t 'l. .*ptuk k.) . -o m a) on_ d ( HOW PAID ♦ 5-11/3 3 4' col `AM O ,02 o -0 cv M RECEIVED FROM a m co ADDRESS U ° o FOR WW1 u4pabi*U iqe! f1t.e f�d r1 I 'OYm a) J (1) 112 a) HOW PAID Ni----S7 `p7 UQ0 CASH CHECK; MONEY ORDER 09s - RECEIPT DATE 3 C24-44 NO. 875©0 4212 3s$ ONZkumA d And Pi`/oo $ /oar"' ,CASH-?::.. CHECK ORDER /00 BY 'fLf CL O STATE O,,, �,Ir1CYy ARTMENT OF PUBLIG`H `LT A°ND EI OPERATE ARETAtL 000 ACCOUNT NUMBER use for all references. 94-2912/99-000. LIABILITY INFORMATION cal*L,soy I Indust.Itycel date ProiouE,bAT�xi-{«:_. amaauib day_. 06 09 03/05/2013 14. THIS LICENSE MUST BE POSTED AFIRE FOLLOWING LOCATION: ORIGINS CATERING COMPANY OR GINS CATERING COMPANY LLC 450 S 8TH STREET BE€�THOUD CO 80513 ORIGINS CATERING COMPANY PO Box -346-12A ATTN ORIGINS CATERING COMP( LICENSEVAteO artless that licensee shown kaired and:`. licensed ip e lness in accordsI pna of the laW an& fat ° do Departneet olPublic,,-tht o dnmenf Any al(erehpne In" rplidegs6, wall aylomabcally mpl OFFICE OF THE SECRETARY OF STATE OF THE STATE OF COLORADO CERTIFICATE I, Scott Gessler, as the Secretary of State of the State of Colorado, hereby certify that, according to the records of this office, A Woman's Work, Inc. is a Nonprofit Corporation formed or registered on 12/03/2006 under the law of Colorado, has complied with all applicable requirements of this office, and is in good standing with this office. This entity has been assigned entity identification number 20061491770. This certificate reflects facts established or disclosed by documents delivered to this office on paper through 03/20/2014 that have been posted, and by documents delivered to this office electronically through 03/21/2014 @ 11:16:40. I have affixed hereto the Great Seal of the State of Colorado and duly generated, executed, authenticated, issued, delivered and communicated this official certificate at Denver, Colorado on 03/21/2014 @ 11:16:40 pursuant to and in accordance with applicable law. This certificate is assigned Confirmation Number 8800101. Secretary of State of. the State of Colorado *********************************************End of certificate******************************************** Notice: A certificate issued electronically from the Colorado Secretary ofState's Web site is fully and immediately valid and effective. However, as an option, the issuance and validity of a certificate obtained electronically may be established by visiting the Certificate Confirmation Page of the Secretary of State 's Web site, http:/'www.sos.state.co.uslbiz'CertiftcateSearchCriteriado entering the certificate's confirmation number displayed on the certificate, and following the instructions displayed. Confirming the issuance of a certificate is merely optional and is not necessary to the valid and effective issuance of a certificate. For more information, visit our Web site, http://wwwsos.state.co.us/ click Business Center and select "Frequently Asked Questions." CERT GS D Revised 08/20/2008 Pat Daniel Pat and Pam Daniel 7107 Reflection Drive Erie, CO 80516 March 13, 2014 Dear Sir or Madam of Weld County: We, Pat and Pam Daniel, of 7107 Reflection Drive, Erie, CO 80516, grant permission to A Woman's Work, Inc. to use our home at the address listed above on Saturday, April 26, 2014 to host the A Woman's Work Evening of Great Tastes fundraiser. • If you have any questions or concerns, please do not hesitate to contact us. Pam Daniel ��-abtes Cy My Map Copyright 2011 Weld County Goverrmert. An rights reserved. Thu Apr 3 2014 03:05:41 PM. CERTIFICATE OF MAILING The undersigned hereby certifies that a true and correct copy of the foregoing Notice of Hearing, was placed in the United States mail, first class mail, postage prepaid, addressed to the following property owners. DATED this 4th day of April, 2014. Anderson South Farm, LLC 6876 County Road 5 Erie, CO 80516-9215 Helen Bryant 2005 James Drive Loveland, CO 80538-3623 Leonard Dolhert 7167 Reflection Drive Erie, CO 80516-9611 Farfrumwurkin, LLLP PO Box 983 Broomfield, CO 80038-0983 David Poss 1754 County road 16.5 Longmont, CO 80501 Reflection Bay Homeowners Association 2185 Pinedrop Lane Golden, CO 80401-9176 Reflection Bay Homeowners Association 7227 Reflection Bay Drive Erie, CO 80516 SF2, LLC PO Box 1227 Longmont, CO 80502-1227 Bureau of Standards 325 Broadway Street Boulder, CO 80305-3337 Bureau of Reclamation PO Box 25007 Denver, CO 80225-0007 0>1Q0.�,� Dep y Clerk to the Board j NOTICE OF APPLICATION FOR TEMPORARY ASSEMBLY Pursuant to the Weld County Code, a public hearing will be held in the Chambers of the Board of County Commissioners of Weld County, Colorado, Weld County Administration Building, 1150 O Street, Assembly Room, Greeley, Colorado 80631, at the time specified. If a court reporter is desired, please advise the Clerk to the Board, in writing, at least five days prior of the hearing. The cost of engaging a court reporter shall be borne by the requesting party. In accordance with the Americans with Disabilities Act, if special accommodations are required in order for you to participate in this hearing, please contact the Clerk to the Board's Office at (970) 336-7215, Extension 5226, prior to the day of the hearing. The complete case file may be examined in the office of the Clerk to the Board of County Commissioners, Weld County Administration Building, 1150 O Street, Greeley, Colorado 80631. E -Mail messages sent to an individual Commissioner may not be included in the case file. To ensure inclusion of your E -Mail correspondence into the case file, please send a copy to ramartinez@co.weld.co.us DATE: April 14, 2014 TIME: 9:00 a.m. APPLICANT: A Woman's Work, Inc PO Box 817 Longmont, CO 80502 REQUEST: Application for a Special Events Liquor License for the sale of malt, vinous and spirituous liquors for consumption by the drink on the premises only, for consumption by the drink on the premises only, for an event scheduled for one day only on Saturday, April 26, 2014, from 6:00 p.m., until 10:00 p.m. LEGAL DESCRIPTION: Reflection Bay, Lot 1; being part of Section: 29, Township 2 North , Range 68 West of the 6th P.M., Weld County, Colorado LOCATION: 7107 Reflection Drive, Erie, CO 80516 (See Legal Description for precise location.) BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO DATED: April 4, 2014 N ! TICE PURS®AINT To THEOR LA*$ W C RI A O1J I HAS REQUESTED THE MEWS. OFFICIALS OF Wfip ara TO c Ate=. , '41O41 } Imo LICENSE AT:.'IRV_Tv (6asi HEARING ON *PPUCATIOII Ti R M AT: C' 'toted, TIME AND DATE: etcomovprilartat44 DATE OF APPUUTlitfilk1th .a4t. IAN BY ORDER DF:LXd testa Carvais � OFFICERS: C0e`p,4zir 1'r • i1 • 1 ' t h To: Weld County Board of Commissioners From: Deputy Mark Mellon Date: April 9, 2014 RE: A Woman's Work Inc. Dear Commissioners, I have researched and found no reported calls for service to 7107 Reflection Drive, Erie, CO 80516 for the Calendar year of 2013 to present day. I fmd no grounds for disapproval for the Temporary Assembly Permit. Respectfully Submitted, Deputy Mark Mellon Community Resource Officer Weld County Sheriffs Office 1950 "O" Street Greeley, CO 80631 Rafaela Martinez From: Sent: To: Subject: Janet Lundquist Thursday, April 10, 2014 9:32 AM Rafaela Martinez RE: Special Event Liquor Application Public Works doesn't have any issues at this time. Janet Lundquist Traffic Engineer Weld County Public Works Dept. P.O. Box 758, Greeley, CO 80632 Tele-970.356.4000 ext 3726 Fax- 970.304.6497 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Rafaela Martinez Sent: Thursday, April 03, 2014 4:20 PM To: Lisa Carpenter; Mark Mellon; Roy Rudisill; Janet Lundquist; Brad Yatabe; Frank Piacentino; Bethany Salzman; Dan Joseph Subject: Special Event Liquor Application Please note, I am still waiting for a copy of the Food Service License for the Caterer. The caterer for the event is "Origins" and it is based out of Berthoud. • Also, another thing to please keep in mind for this particular Application, The event date is set to be on April 26, 2014. In order to allow time for the State to process the Liquor part of the Application, the hearing date for this application will be April 14, 2014. In accordance with the procedure for Special Event Liquor checks, please review all records on the following document for any associated reports/incidents during the last year and return your report to the Weld County Clerk to the Board's Office within one week. Your report will be used by the Board of County Commissioners in considering renewal of the Temporary Assembly application. PLEASE RESPOND NO LATER THAN: April 9, 2014 Applicant: A Woman's Work, Inc. Thank you, 1 Rafaela Martinez From: Sent: To: Subject: No issues with this event. Dan Joseph Thursday, April 10, 2014 5:00 PM Rafaela Martinez RE: Special Event Liquor Application Dan Joseph CP-FS Food Program Coordinator Weld County Department of Public Health and Environment 1555 North 17th Avenue Greeley, CO 80631 phone: 970.304.6415 x 2206 fax: 970.304.6411 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Rafaela Martinez Sent: Thursday, April 03, 2014 4:20 PM To: Lisa Carpenter; Mark Mellon; Roy Rudisill; Janet Lundquist; Brad Yatabe; Frank Piacentino; Bethany Salzman; Dan Joseph Subject: Special Event Liquor Application Please note, I am still waiting for a copy of the Food Service License for the Caterer. The caterer for the event is "Origins" and it is based out of Berthoud. • Also, another thing to please keep in mind for this particular Application, The event date is set to be on April 26, 2014. In order to allow time for the State to process the Liquor part of the Application, the hearing date for this application will be April 14, 2014. In accordance with the procedure for Special Event Liquor checks, please review all records on the following document for any associated reports/incidents during the last year and return your report to the Weld County Clerk to the Board's Office within one week. Your report will be used by the Board of County Commissioners in considering renewal of the Temporary Assembly application. PLEASE RESPOND NO LATER THAN: April 9, 2014 Applicant: A Woman's Work, Inc. Thank you, MEMORANDUM To: Rafaela Martinez, Deputy Clerk to the Board April 11, 2014 From: Bethany Pascoe, Zoning Compliance Officer, Dept. of Planning Services Subject: LC0022 Review of the following Special Events (SE) Permit by the Department of Planning Services the following recommendations were noted: Applicant: A Woman's Work, Inc PO Box 817 Longmont, Co 80502 Property Owner: Nick Sekich Jr. 6790 CR 32 Platteville, Co 80651 Location of Event: 7107 Reflection Dr Erie, CO 80516 Dates and Time of Event: April 26, 2014 from 6:00 pm -10 pm General Information: Zone District: Agriculture Comments: This site to be utilized in this request is situated within the boundaries of a subdivision (Reflection Bay). Reflection Bay is zoned PUD with Estate and Agricultural Uses (Z-544) TA = Temporary Assembly application SE= Special Events application SERVICE, TEAMWORK, INTEGRITY, QUALITY U.S. Postal ServiceTM CERTIFIED MAILTM RECEIPT (Domestic Mall Only; No Insurance Coverage Provided) Postage Certified Fee Return Receipt Fee (Endorsement Required) Restricted Delivery Fee (Endorsement Required) Total Postage 8 Fees Postmark Here Sent To nr Kali. _C2a,ddia---fk-Licga ria ci enc thane. Street, Apt. Ylo.; f or PO Box No. aao1 I8i" City, State, ZIP+4 _ 4Flftb� CO pOSO,?j • 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. D. Is delivery address different from Item 1? 0 Yes If YES, enter delivery address below: 0 No 1. Article Addressed to: Aim''- M. Kerb Gaddls 4 Woms-h'la bJor c) <201/ ig*- I-lt a C onB rn w i-, Co gpCo 3 2. Article Number (Transfer from service lobe° PS Form 3811, February 2004 Domestic Return Receipt 3. Service Type ra Certified Mall ❑ Registered ❑ Insured Mall ❑ Express Mall ❑ Return Receipt for Merchandise 0 C.O.D. 7004 2890 0003 5709 0413 10-M-1640 RETAIN THIS COPY FOR YO W R COHOS. ja E ❑ 0029 9594 ❑4 a la ❑ I $�o J AA d r- k fl 1� 11 !y I C 2 it ▪ eEv ❑ a G ❑ I a a m m m m E o $ eoTs Xw m u • a co r e m t u d ea {6 Y m • g. Ci O.i Y V e �0 ea - 4. a C 0 c d E 6 L E H y Hello