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I83b5 PERSONAL PROPERTY INVENTORY JWe InsuredDm ohnoon Home.owhlys..tns Dale State aw, in some slalesregures thal we acvise you o! the lollowingA per RCV-FORM $ Q15 Beccnwood Qr Son comrils insurance laud, which is a crime d he or she knowingiy and. RCV-DATE: with nen to deraud any nsurance oompany or oter psrson es a sialernent PAGE NO. B n e ss ss p any lase incamplele or nisleading inomation. Company Use ONLY DESCRIPTION OF ITEM DATE OF COST TO DEPRE- AMOUNT REPLACEMENT REPLACEMENT (IF APPLIANCE* GIVE MAKE. WHERE PURCHASED ORIGINAL REPLACE CIATION OF RECEIPTAGHEED COST MODEL, ETC.) NAME AND ADDRESS} PUACHASE TODAY % (IF ANY) $ CLAIM AMOUNT CLAIM NO ronotu 19982600 Pursonal 1qq7- $1000 pickxes t Fromes inoffite vartous 2000 pawn Snop 1995 laa5 Smay V Z.F0ldop mahe|chaus 1997 $12000 Wawaxk masters For`dismb hon 2500 prsooal preaching fanes Kinooom..tapes. 2000 $400 Sesn's 19.90 199 $60 Limns 3 [harge Mamrs Mkharls. J Garsls.lug 195-200 10: -0002* AUG. *Applance moans Range, Relrigeralo, Freezer, TV, Slereo, Window AC Unit, elc.. TOTALS