fo3oWing .tionm(s),Ili i Nom: • . . . . • :. .• • •• . • • • • • .'• . . 0.- - • • .. TOTAL AMOUNT; $ • . • 3.:i' • aldidocial Iratmedom ordorod, including spa° m onthly amount, beep date, due dela, orJant & several:— • NAME' TOTAL AMOUNT: $ Additional kwouettom ordered, Including