kik) lw ge-fus7roN t 1 I certify that the statements made by me on Ihts lonn are true. HOS SIB Page Nil Amount FortvaM l'A t1555. 1 -4 3 kri- Mtal ta Date bl il Fil 2 6 3 3 h 2 () EFTA01699170 Date 4g--- .00.. Airmail Make and Model Arcraft Idenfficaton Mark Points of Departure ik Arrival M