v2402-317

tFORM 1040 O

hatadui RVraaw Smtn

UNITED. STATES

DEPARTING AUEN INCOME TAX RETURN

For Taxable Period

Do not write b I

"^1

SAMJ. ANIJ HOME ^"

i

WITH IHfeMlTTANi

eaxitn i 'i

I- Niw r w l i i wi ^tim cot intW

Mt (anod la endear bettiwit vittiui ilw I oiuii g)uia u

n - NwilllliitltH till ( thB riMit g Cud) with na U

.,. M51 not hvini as mm or phe o h u i ft tiMnia mt Imw**' IM tn

bsrtm ui or t'lire o* bwlnM" th"^ . .

V pwtdtnt any jiu ii u i U d wnh

M4li(M%orUM

It. tmalaitiDWiMOatrMrtMJM.

I iwmliwiE.buidoKMJi5jMjg?).

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