c^POST OFFICE DEPARTMENT Ma 



g THIRD ASSISTANT POSTMASTER GENERAL ■"^b 



§ DIVISION OF MONEY ORDERS Stamp of Issidng Offfee 



O 



g FEE 



o 



^ The Postmaster 

 will insert 



5 here 



*T the office drawn on, vrhen the office 

 I named by the remitter does not trans- 

 H act money-order business 



2 Spaces aboFe this line are for the Postmaster's record, to be filled in by him 2 



i Application for Domestic Money Order i 



G Spaces b«low to be filled in by purchaser, or, if necesaary» ^ 

 ^ by another person for him 



2- Amount — S 



;;; ''' ""i^^ffpEU DoUars Cents ? 



I > 



g To be I 53 



K paid toj CNazne of Derson or firm for whom order is inteaded) »^ 



fti 



O Whose] 

 >- 



address > tr 



is] Street » 



g City 1 "0 



O and ^ g 



S State! r 



^^ . &* 



2 Sent by JL 



•*• CNamo of Bender) 5» 



P Street ^ 



Z City 

 cj and 

 g State 



PURCHASER MUST SEND ORDER AND COUPON TO PAYEE 



(FOR FEES SEE OTHER SIDE) cie-8391-l 



