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DESCRIPTION | BAW Boo Cc PAR Shoes Bu shods F Snieas . 425 each S Suats Ry /PrinsTtRie SKGRAY § 300. ‘CA, ; \ WM Uru eisaclu 5 wroersners bIS onKh S under Panrs ¥ 1S each ID HAQOKERCMEFS - $1 Each 8 Soct<s Gores : 4 1Seack AANES OLEQCOAT CAShmere. Swearer Box Choco Lare SA OLE TOTAL VALUE U.S. $ 4 (local currency) " ~ Do you have private insurance covering this loss? MV no tnciiaulnawacne” ) 22500" If so, state company and address: a , , 3 124 50° SIGNATURE: NOTE: PLEASE ATTACH YOUR BAGGAGE TAG(S) AND PASSENGER COUPON OF YOUR TICKET ———eeeeee—eeeeeeeeeeaeS=sIoeeaeaeaeaeeeeeeeeeEeeeEeeeeaaEaaaee eS FOR USE IN USA ONLY ¥... ... It is expressly understood and agreed by me that the furnishing of this form and any assistance furnished me by” , . employees ot DELTA AIR LI & a are ‘actsof couttesy: and shall not constitute a waiver of any rights or an admission of liability by or on the part of DELTA AIR LINES, INC, teupto'vess Br phpote: Minster information and/or documents relating to this statement which are required by tio LTAA ALR LINES, INC? in Bike by me upon request and shall be considered part of this statement. 0 fo heveby warrant the foregoinystatement and those on the accompanying forms to be accurate, com fae) . fey 7 be in the amd tots 12,350¢ The United Stat wd, he has investigative jurisdictionu; CEMA Télating to sending false or fraudulent Claims through the United States mails. Ampsuchclain ceived by DELTA AIR LINES, INC., are reported to the United States Postal Authorities. Losses of baygqage in interstate shipment or of articles from such baggage come within the purview of federal statutes relating to thefts from Interstate Shipment.and, therefore, ere. subject to investigation by the Federal Bureau of Investigation. ‘ . : Se ete, true and | hereby make a claim against S 1977 ia State of Country of Sworn or affirmed the truth of before me this N14, day of \f-3 19.7-) e