ment of $50.00 payable to the Dept. of Stria USAO_000848 EFTA_000 18758 EFTA00168505 65L81000-171dE 6178000OVS11 1 • Statism of Addresses a Dintton, Pert C IN WITNESS WHEREOF, this certificate has.tgen sulmribecIS ? O).5.,1O91) , by the undersigned who affirms that the statements made herein