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AMERICAN FAMIL FOR FOR PER <br /> AP ROVAL U INFORMATION EQUEST J)) <br /> AUTO HOME BUSINESS HEALTH LIFE® �� <br /> DATE (/ <br /> �`-i re e r,,,,,,,..3 6,,,,te___- <br /> al.7 <br /> MEMO a.`PcP <br /> "- ile---ii <br /> az l <br /> u jECT / / <br /> LICY OR REF. t <br /> , � lls S A-e <br /> MESSAGE <br /> o.k I 7/a y 7 �: --� ��,�,�/"Ile,' 762<_,T€ 01-..e...e.'t-eci • 'f' /Yi 0440P <br /> ,ite_ a f-a64 L �,' <br /> , <br /> e,z,e„, A -01. ,-z-,:c,,d' _--tet P,-..-P-eace___ <br /> 3, Y2'62.-'ne ....e.A.C.3. af".6.1'7 .' Af <br /> i..-,-,, ; cce='1---4. - i\c- .A,.4_(2- 6. -e —.S 4-0e_ Ay H of,h) <br /> _FOLD - _ P / -/ -a <br /> /1,e_ Pt-e--et-t-.-c---el Ge---C-e-A--4"0--P--9 r0L -- P 7,-44„4...„.,,,..,)) o -L. =__--e-‹ <br /> � <br /> Ad' . , . _ T %i : . 1 P i 1 I , <br /> ■ <br /> JAMES VALE AGENCY r P ' �— <br /> 207 S. LUDINGTON ST., BOX 41 <br /> COLUMBUS, WISC. 53925 <br /> 623-4488 Signature and Date <br /> AG 10780 Rex-.6/94 Sender:Keep duplicate copy-send original&triplicate copy • Receiver:Keep triplicate copy-return original copy <br /> 1 <br />