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Home My WebLink About20143925.tiffRESOLUTION RE: APPROVE APPLICATION AND REPORT OF CHANGES FOR EATON COUNTRY CLUB, DBA EATON COUNTRY CLUB, AND AUTHORIZE CHAIR TO SIGN 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, Eaton County Club, dba Eaton Country Club, holder of a Hotel and Restaurant with Option Premises License in Weld County, Colorado, has presented the Board with an Application and Report of Changes, and WHEREAS, said change is as follows: Brooke Speck replaces Kory Atkinson as Manager, and WHEREAS, after study and review, the Board deems it advisable to approve said Application and Report of Changes. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Application and Report of Changes submitted by Eaton Country Club, dba Eaton Country Club, be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said application. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 22nd day of December, A.D., 2014. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST: drtaceo S , ,. / :04. Weld County Clerk to the Board BY: y Clerk to t APPROVED AS TO FORM. County Attorney William F. Garcia Date of signature: I —'I6- Douglas I&ademacher, Chair )1.X.42- /A . - A---" Kirkme , Pro-Te arbara ye mean P. Conway 0,Oa) 3)23 2014-3925 LC0037 DR 8442 (09124/09) Page 1 COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION DENVER, COLORADO 80261 (303)-205-2300 PERMIT APPLICATION AND REPORT OF CHANGES FOR DEPARTMENT USE ONLY CURRENT LICENSE ALL ANSWERS LOCAL LICENSE APPLICANT SHOULD NUMBER MUST BE PRINTED FEE $ \On 3°\oaco TO ORDER CALL (303) 370-2165 IN BLACK INK OR TYPEWRITTEN OBTAIN A COLORADO LIQUOR & BEER CODE BOOK 1 Applicant is isa Ly Corporation ❑ Partnership ❑ Individual Company PRESENT LICENSE NUMBER \ 40 D O 3`\ 000a • Limited Liability 2. Name of Licensee E04--kt\C\ C, i\)Jrf\LA-V C \ A b 3. Trade Name Sc>`vr.2., 4. Location Address 3 -1,7"\ wcs— 3°\ City �a-kt\r-. SELECT THE APPROPRIATE SECTION BELOW Section A -Manager rag/change County W VA\ AND PROCEED TO THE INSTRUCTIONS Section Warehouse Branch Corp. or Location Alter or x ZIP %.0\4 C Storage House Trade Permit Modify Total Fee Premises Total Fee Facility Fee \S ON PAGE 2. Permit (ea) $100.00 Permit (ea) 100.00 Name Permit (ea) . 50 00 (ea) 150.00 Premises • License Account �� 1983-750 (999) LManager's `^ 2,S,3:\ 00002210-100 No. '1 (999) ❑ Retail Registration (Hotel & Restr.)..$75.00 Manager's Registration (Tavern) $75.00 Change of Manager (Other Licenses) NO FEE 2200-100 (999) • Wholesale 2260-100 (999) ❑ Change 2230-100 (999) ❑ Change 2012.750 (999) • • 2280-100 (999) • Change, $150.00 Section 8 —Duplicate License of Optional x to Existing H/R • Liquor License 2270-100 (999) No. 2220-100 (999) • Addition $100.00 1988-100 (999) ❑ Addition $75.00 x of Related Total to Resort Complex $50.00 • Duplicate License DO NOT WRITE IN THIS SPACE - FOR DEPARTMENT OF REVENUE USE ONLY DATE LICENSE ISSUED LICENSE ACCOUNT NUMBER PERIOD -750 (999) -100 (999) The State may convert your check to a one time electronic banking transadion. Your bank account may be debited as early as the same day received by the State. If converted, your check will not be returned. If your check is rejected TOTAL due to insufident oruncotededfunds, the Department of Revenue may collect the payment amount directly from your bank account electronically. AMOUNT DUE $ .00 2014-3925 DR 8442 (09/24/09) Page 2 INSTRUCTION SHEET FOR ALL SECTIONS, COMPLETE QUESTIONS 1-4 LOCATED ON PAGE 1 Section A To Register or Change Managers, check the appropriate box in section A and complete question 8 on page 4. Proceed to the Oath of Applicant for signature (Please note: Hotel, Restaurant, and Tavern licensees are required to register their managers). Section B For a Duplicate license, be sure to include the liquor license number in section B on page 1 and proceed to page 4 for Oath of Applicant signature. Section C Check the appropriate box in section C and proceed below. 1) Fora Retail Warehouse Storage Permit, go to page 3 complete question 5 (be sure to check the appropriate box). Submit the necessary information and proceed to page 4 for Oath of Applicant signature. 2) Fora Wholesale Branch House Permit, go to page 3 and complete question 5 (be sure to check the appropriate box). Submit the necessary information and proceed to page 4 for Oath of Applicant signature. 3) To Change Trade Name or Corporation Name, go to page 3 and complete question 6 (be sure to check the appropriate box). Submit the necessary information and proceed to page 4 for Oath of Applicant signature. 4) To modify Premise, go to page 4 and complete question 9. Submit the necessary information and proceed to page 4 for Oath of Applicant signature. 5) For Optional Premises or Related Facilities go to page 4 and complete question 9. Submit the necessary information and proceed to page 4 for Oath of Applicant signature. 6) To Change Location, go to page 3 and complete question 7. Submit the necessary information and proceed to page 4 for Oath of Applicant signature. DR 8442 (09/24/09) Page 3 t. W Ili 5. Retail Warehouse Storage Permit or a Wholesalers Branch House Permit etc.) • Retail Warehouse Permit for: ❑ On —Premises Licensee (Taverns, Restaurants • Off —Premises Licensee (Liquor stores) ❑ Wholesalers Branch House Permit Address of storage premise: City , County Zip Attach a deed/ lease or rental agreement for the storage premises. Attach a detailed diagram of the storage premises. 6. Change of Trade Name or Corporation Name supporting documents) of State, or of State and ■ Change of Trade name / DBA only WS 1% ■ Corporate Name Change (Attach the following 1. Certificate of Amendment filed with the Secretary 2. Statement of Change filed with the Secretary 3. Minutes of Corporate meeting, Limited Liability Members meeting, Partnership agreement. Old Trade Name New Trade Name Old Corporate Name New Corporate Name ,r, •' .C9.: a 7. Change of Location NOTE TO RETAIL LICENSEES: An application to change location has a local application fee of $750 payable to your local licensing authority. You may only change location within the same jurisdiction as the original license that was issued. Pursuant to 12-47- 311 (1) C.R.S. Your application must be on file with the local authority thirty (30) days before a public hearing can be held. Date filed with Local Authority Date of Hearing (a) Address of current premises City County Zip (b) Address of proposed New Premises (Attach copy of the deed or lease that establishes possession of the premises by the licensee) Address City County Zip (c) New mailing address if applicable. Address City County State Zip (d) Attach detailed diagram of the premises showing where the alcohol beverages will be stored, served, possessed or consumed. Include kitchen area(s) for hotel and restaurants. DR 8442 (09/24/09) Page 4 OATH OF APPLICANT I declare under penalty of perjury in the second degree that I have read the foregoing application and all attachments thereto, and that all information therein is truecorrect. and complete to the best of my knowledge 8. Change of Manager or to Register the Manager of a Tavern or a Hotel and Restaurant liquor license. (a) Change of Manager (attach Individual History DR 8404-I H/R and Tavern only) Former manager's name KCN-t P kt P.Scr New manager's name ?,cc' c Sc-0—C-X_. (b) Date of Employment \a rk oZO\4 Has manager ever managed a liquor licensed establishment? Yes IiNo ❑ Does manager have a financial interest in any other liquor licensed establishment? Yes ❑ Noe' If yes, give name and location of establishmenRi oun (,p/ rn±h , 4 C(1t 31'1.00 In 18/`.1O11 9. Modification of Premises, Addition of an Optional Premises, or Addition of Related Facility NOTE: Licensees may not modify or add to their licensed premises until approved by state and local authorities. (a) Describe change proposed (b) If the modification is temporary, when will the proposed change: Start (mo/day/year) End (mo/day/year) NOTE: THE TOTAL STATE FEE FOR TEMPORARY MODIFICATION IS 5300.00 (c) Will the proposed change result in the licensed premises now being located within 500 feet of any public or private school that meets compulsory education requirements of Colorado law, or the principal campus of any college, university or seminary? (If yes, explain in detail and describe any exemptions that apply) Yes ❑ No ❑ (d) Is the proposed change in compliance with local building and zoning laws? Yes ❑ No ❑ (e) If this modification is for an additional Hotel and Restaurant Optional Premises or Resort Complex Related Facility, has the local authority authorized by resolution or ordinance the issuance of optional premises? Yes ❑ No ❑ (f) Attach a diagram of the current licensed premises and a diagram of the proposed changes for the licensed premises. (g) Attach any existing lease that is revised due to the modification. REPORT AND APPROVAL OF LOCAL LICENSING AUTHORITY (CITY / COUNI"r) The foregoing application has been examined and the premisesbusiness conducted and character of the applicant is satisfactory and we do report that such permitif grantedwill comply with the applicable provisions of Title 12. Articles 46 and 47, C.R.S.. as amended. THEREFORE, THIS APPLICATION IS APPROVED. Local Licensing Authority (City or ounty) . I Date filed with Local Authority NCU`ein 3 l2, 20i4 Signal re Weld County, Colorado Title I Date Chair Pro —Tern DEC 2 $ 2614 arbara Kirkme er Wdld Count Commissioner REPORT OF STATE LICENSING AUTHORITY The foregoing has been examined and complies with the filing requirements of Title 12, Article 47. C.R,S.. as amended. Signature Title Date DR 8404-I (01/06/05) COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION 1881 PIERCE STREET RM 108A DENVER CO 80261 INDIVIDUAL HISTORY RECORD To be completed by each individual applicant, all general partners of a partnership, and limited partners owning 10% (or more) of a partnership; all officers and directors of a corporation, and stockholders of a corporation owning 10% (or more) of the stock of such corporation; all limited liability company MANAGING members, and officers or other limited liability company members with a 10% (or more) ownership interest in such company and all managers of a Hotel and Restaurant or a Tavern License. NOTICE: This individual history record provides basic information which is necessary for the licensing authority investigation. All questions must be answered in their entirety or your application may be delayed or not processed. EVERY answer you give will be checked for its truthfulness. A deliberate falsehood or omission will jeopardize the application as such falsehood within itself constitutes evidence regarding the character of the applicant. 1. Name ofBusiness ssr v-- tAviN C nYL CA \o 2. Your Full Name (last, first, middle) S�e Oc� ?IC t U�X Oo\cUC pj.S 3. List any other names you have used. \Y\CONLit— voOY_.e.. CUxFhan3YU g 4. Mai ing address (if different from aAQaQ at ‘(1\\t residence) Gv . co SoL03\ Home Telephone 0-10) )g 1- ?Asa 5. List all residence addresses below. Include current and pr ous addresses for the past five years. STREET AND NUMBER CITY, STATE, ZIP FROM TO Current a\ce 0 1k f�e� (In C..o $O�31 9 1.- G.��Yc vRk- Previous 3 -)yo E a sk (2-( Car to zzoa k 3 to 511a, 6. List all current and former employers or businesses engaged in within the lath five years (Attach separate sheet if necessary) NAME OF EMPLOYER ADDRESS (STREET, NUMBER, CITY, STATE, ZIP) POSITION HELD FROM TO Cdr Uvun CA 319_1/40lwof- 3cikC7D-1u\r. c>a 101016 sr 3 1ci c w 'Food is NC.kila,Cn Ur • \ \'cS ' eV Care tO\o3 av Si 5\13 a/ A, W'4M-4V (.- V\ F .,Cat, ,CO 3i, o CAMoU_ aPk lavta KLCAS'scfD ak �vri&Q C'.� aI �a I\ 113 7. List the name(s) of relatives working in or holding a financial interest in the Colbrado alcohol beverage industry. NAME OF RELATIVE RELATIONSHIP TO YOU POSITION HELD NAME OF LICENSEE 8. Have you ever applied for, held, or had an interest in a State of Colorado inventory, to any liquor or beer licensee? If yes, answer in detail. Liquor orBeeLicense, or loaned money, furniture or fixtures, equipment or Yes M NO 9. Have you ever received a violation notice suspension or revocation, for a liquor law vio ion, or have you applied for or been denied a liquor or beer license anywhere in the U.S.? If yes, explain in detail. Yes Q `p. `\. to \k1 'fie.-w“.r\ Qt 3a\\ \N aot st CaYea .�,,J cO Covik Say o- S \O1\A, - a 1 ' Ovskio 5`k1,, UcurbLor. Wa,3 cs* Q %ktiS,c,3 Cosa 10. Have you ever been convicted of a crime or received a suspended sentence, deferred sentence, or forfeited bail for any offense in criminal or military court or do you have any charges pending? Include arrests for DUI and DWAI. (If yes, explain in detail.) Yes No \ Otk- tttis- \rn r3cat_whtun was Ycclt..c_ ck cL- OW and. c)J.Qkvt L ( C \ CkY\\StiQd cu\ Cowl t v rav-4o l .pl `C e kkA. vt Arv.s 5 kiJ\,-.un \ oli d • 11. Are you currently under probation (supervised or unsupervised), parole, or completing the requirements of a deferred sentence? (if yes, explain in detail.) H I Yes Milo 12//Have you ever had any STATE issued licenses suspended, revoked, or denied including a drivers license? (If yes, explain in detail.) kl Yes No tv...\ dtx : ve A;c. \A cix\io , cr d. t , k -O v.4..90,:t d iu.tak ukticc /, wrrc i, gout c -- rsO\r e. st,ov, as \ Qty".. -,a -DA- & d chRcciv, beta u.c4e t•(..\ Qo, pesnavk, ca&-tr:k- °tk • \\sd koct O. 'ea PERSONAL AND FINANCIAL INFORMATION LoJetv i9t- Unless otherwise provided by law in 24-72-204 C.R.S., information provided below will be treated as CONFIDENTIAL. Colorado liquor licensing authorities require the following personal information in order to determine your suitability for licensure pursuant to 12-47-307 C.R.S. 13a. Date of Birth b. Social Security Number SSN ' c. Place of Birth d. U. . Citizen? Yes - 'No C� e. If aturalized, State where f. When g. Name of District Court h. Naturalization Certificate Number i. Date of Certification j. If an Alien, Give Alien's Registration Card Number k. Permanent Residence Card Number I. Height m. Weight S V \%O n. Hair Color o. Eye Color p. Sex q. Race �.z,n6.Q.I �\ 1O "c\t)\,i . l r. D9 you have a current Driver's License? If so, give number and state \-/Yes _ No Cioo— Financial information. a. Total purchase price $ (if buying an existing business) or investment being made by the applying entity, corporation, partnership, limited liability company, other $ b. List the total amount of your investment in this business including any notes, loans, cash, services or equipment, operating capital, stock purchases and fees paid $ c. Provide details of Investment. You must account for the sources of ALL cash (how acquired). Attach a separate sheet if needed. Type: Cash, Services or Equipment Source:Name of Bank; Account Type and Number Amount d. Loan Information (attach copies of all notes or loans) Name of Lender and Account Number Address Term Security Amount 15. Give name of bank where business account will be maintained; Account Name and Account Number; and the name or names of persons authorized to draw thereon. CoSV-IL -k-- s Tv...&k Eo ,v\ C,FNAN\�1,, L\uio \o \-Ia3t t , S4tea\L 2 F)0wdkoih Soh sad- . Y.--Liiki Wwfv- 4 -,SAO ko nO Oath of Applicant I declare under penalty of perjury in the second degree that this application and all attachments are true, correct, and complete to the best of my knowledge. Authorized Signal Title R--e-SS% t Ldvt,...frvMCOra AO1 Date W ( \\ ;c4 November 12, 2014 To whom it may concern, My name is Shelly Bowden and I am the Office Manager at the Eaton Country Club. I am writing this letter in regards to Brooke Speck, the Restaurant and Bar Manager here at the Club. Brooke has been employed as the Restaurant and Bar Manager since March 18, 2014 and in that time she has made tremendous strides for the betterment of the Club. Brooke's dedication is only matched by her willingness to work and empower the employees to succeed in a healthy and safe environment. Brooke leads with determination and passion for the wellbeing of our customers and members. She has implemented numerous trainings and guidance to the employees of the restaurant and bar. Brooke has established structure and policies that have improved the safety of our employees and as well as our customers. I feel Brooke is qualified and capable to direct and regulate the liquor service here at the Eaton Country Club. I enthusiastically recommend Brooke Speck to be added to the liquor license. I have every confidence that Brooke Speck will not only regulate the consumption of alcohol, but do so in a professional manner. Sincerely, Shelly Bowden Office Manager Eaton Country Club 4 a Kyle Merritt 37661 CR 39 Eaton, CO 80615 kylem@eatoncc.net November 6, 2014 Colorado Department of Revenue Liquor Enforcement Division Denver, CO 80261 (303)-205-2300 To whom it may concern: I'm writing on behalf of Brooke Speck regarding her as manager and person in control of the Eaton Country Club liquor license. I am the Director of Operations at the Eaton Country Club (ECC). I have worked at ECC for a year and a half and have worked with Brooke for the last seven months. Brooke has been an extremely positive addition to ECC. Brooke has implemented thorough training programs for all of our servers, bartenders and anyone else who might handle alcohol. In addition to training, Brooke has established rules and a code of conduct for our employees to follow. These rules and training have helped provide a safe and friendly place for our employees to work and for our customers to enjoy. I feel very confident in Brooke's ability to help ECC create a fun, family atmosphere while still serving alcohol on our premise. I feel very confident that all alcohol related issues will be handled in a professional manner and up to legal standards. Sincerely Kyle E. Merritt Director of Operations Ryan Fagerberg 3732 Valley Crest Dr Timnath, CO 80547 970-396-8711 To whom it may concern, I served on the Board of Directors at the Eaton Country Club for nearly two years. During the last six months of that time, Brooke Speck was the individual responsible for liquor sales, ordering, and training of servers. I was impressed with Brooke's attention to detail and ability to provide leadership. Through the implementation of training and operating policies, Brooke has successfully applied safeguards at the Eaton Country Club. 1 am confident that Brooke will continue to create an environment that is conducive to responsible behavior. Brooke will continue to ensure that the Eaton Country Club is always legally compliant with all alcohol related manners. Due to all of this, I give my full recommendation for the Eaton Country Club to receive their liquor license. Ryan Fagerberg 11-7-14 20141202-08311 DATE 11/25/2014 SO WELD COUNTY RECORDS GREELEY 1950 "0" STREET GREELEY, CO 80631 RE: SPECK,BROOKE MARQUIS DATE OF BIRTH: SOC: xxx-xx- The Colorado arrest record for the person noted to follow. The Colorado Bureau of Investigation's database contains detailed information of arrest records based upon fingerprints provided by Colorado law enforcement agencies. Arrests which are not supported by fingerprints will not be included in this database. On occasion the Colorado criminal history will contain disposition information provided by the Colorado Judicial system. Additionally, warrant information, sealed records, and juvenile records are not available to the public. Since a record may be established after the time a report was requested, the data is only valid as of the date issued. Therefore, if there is a subsequent need for the record, it is recommended another check be made. Falsifying or altering this document with the intent to misrepresent the contents of the record is prohibited by law and may be punishable as a felony when done with intent to injure or defraud any person. Sincerely, Ronald C. Sloan, Director Colorado Bureau of Investigation ATTN: SO WELD COUNTY RECORDS GREELEY COLORADO BUREAU OF INVESTIGATION - IDENTIFICATION UNIT 690 KIPLING STREET,SUITE #3000, DENVER, COLORADO 80215 (303)239-4208 THIS IDENTIFICATION RECORD IS FOR LAWFUL USE ONLY AND SUMMARIZES INFORMATION SENT TO THE COLORADO BUREAU OF INVESTIGATION FROM FINGERPRINT CONTRIBUTORS IN THE STATE OF COLORADO. UNLESS FINGERPRINTS ACCOMPANIED YOUR INQUIRY, THE COLORADO BUREAU OF INVESTIGATION CAN NOT GUARANTEE THIS RECORD RELATES TO THE PERSON IN WHOM YOU HAVE AN INTEREST. IF THE DISPOSITION IS NOT SHOWN OR FURTHER EXPLANATION OF AN ARREST CHARGE OR DISPOSITION IS DESIRED, THAT INFORMATION MAY BE OBTAINED FROM THE AGENCY WHO FURNISHED THE ARREST INFORMATION. Page 1 20141202-08311 ONLY THE COURT OF JURISDICTION OR THE RESPECTIVE DISTRICT ATTORNEY'S OFFICE WHEREIN THE FINAL DISPOSITION OCCURRED CAN PROVIDE AN OFFICIAL COPY TO ANY SPECIFIC DISPOSITION. STATE LAW GOVERNS ACCESS TO SEALED RECORDS. BECAUSE ADDITIONS AND DELETIONS TO A CRIMINAL HISTORY RECORD MAY BE MADE AT ANY GIVEN TIME, A NEW INQUIRY SHOULD BE REQUESTED WHEN NEEDED FOR SUBSEQUENT USE. *************************** NAME(S) USED: PHYSICAL: DATE(S) OF BIRTH: PLACE(S) OF BIRTH: SCARS/MARKS: IDENTIFICATION MCPHEE, BROOKE MARQUIS SPECK, BROOKE MARQUIS *************************** SEX: F RACE: W HGT: 507 WGT: 145 EYE: HAZ HAIR: BLN SKN: CO TAT BACK ************************** ARREST DATE ARRESTED AGENCY ARREST NUMBER NAME USED CHARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE ARREST DATE ARRESTED AGENCY ARREST NUMBER NAME USED CHARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE CHARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE CRIMINAL HISTORY Cycle 001 *.************************* 08/28/2003 GREELEY POLICE DEPARTMENT 0308695 MCPHEE, BROOKE MARQUIS 01 FAIL TO APPEAR GREELEY MUNI FTA -- 2 COUNTS MISDEMEANOR 08/28/2003 Cycle 002 12/13/2006 LARIMER COUNTY SHERIFF'S OFFICE 0616589 MCPHEE, BROOKE MARQUIS 01 DRIVING UNDER THE INFLUENCE MISDEMEANOR 12/13/2006 02 TRAFFIC OFFENSE SPEED LIMIT VIOLATION MISDEMEANOR 12/13/2006 *CRIMINAL JUSTICE AGENCIES MAY NOT HAVE PROVIDED ALL ARRESTS, *CHARGES OR DISPOSITIONS TO THE CBI. THIS RECORD SHOWS ALL *ARRESTS, CHARGES & DISPOSITIONS THAT WERE PROVIDED, UNLESS *ACCESS TO THEM HAS BEEN LIMITED BY COURT ORDER. *FALSIFYING OR ALTERING THIS RECORD WITH THE INTENT TO MISREPRESENT* *THE CONTENTS OF THE RECORD IS PROHIBITED BY LAW, AND MAY BE *PUNISHABLE AS A FELONY WHEN DONE WITH THE INTENT TO INJURE OR * Page 2 20141202-08311 -DEFRAUD ANY PERSON. ---- END OF RECORD MEETING DISSEMINATION CRITERIA - 11/25/2014 15:42MT Page 3 P.O. BOX 240 EATON, CO 80615 (970) 454-2479 Po, Sited CACMi BV -638- 1 Q /0 3, 5099 Thirty -Eight Dollars and Fifty cents*******************************************.**** ***** ****** ***** ***, Colorado Bureau of Investigations Memo: 7648 Re o ..31..b.'9a 11/11/2014 $38.50 /'? 7648 A 0 AUTHORIZED SIGNATURE . 0 a T. O .0 N O >; c‘3 co m co c w • t 2 O o ti U a m N N N O N UaC7 P. 0 O U T m c v 0 U 0 a) N 0 Co O rC o m m m O a O RECEIPT RECEIVED FROM ADDRESS ZAk, iw.r l iLiftli,-' citA who° $ L,50 . FOR *y, ctt.ta DATE —INICA IJVADL L:l2,t (2.414__ NO Cow,thitTh 1111&) HOW PAID CASH CHECK ) US -0 0 MONEY ORDER RECEIPT RECEIVED FROM ADDRESS e I'u.c.ac h.ul, r c 4 t`�°j oc — --- .2-5b,00 FOR J- O037 BY DATEO_Gl,'r2� • �,� ZG6'/ NO. f HOW PAID CASH CHECK MONEY ORDER ''5% LruLu. 11o10 1. 003n BY Hello