Customs Form 5269 
TREASURY DEPARTMENT 
99, 0: A. M.; 8.40, 24.36, C. R. 
Form approved by 
Comptroller General, U. S., December 11, 1953 
(Jan. 1954) 
NOTICE OF REFUND 
BUREAU OF CUSTOMS 
No. 
NEW YORK, N«Y 
., 19 . 
There is a refund due you by the United States on 
as per the particulars noted below, 
is attached. 
Check in payment 
Kind of 
Entry 
Entry No. 
Date of 
Entry 
Case or 
Voucher No. 
AMOUNT 
Customs 
Collections 
Internal Revenue 
Collections 
REMARKS 
Totals 
Total Refund 
$e v 
V'J 
DILL 
Collector of Customs, 
D® H, Qoldv/ater 
Fiscal uccountant 
0. S. GOVERNMENT PRINTING OFFICE 
16 - 12399-4 
