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V% (}fl ‘ UNIT

Inmate NameN ( Date i ( (S lnrnateNo.HOL4LQ I

The above namdJnmate is required to come to te mail room f) (Date and Time)

regarding the following matter:

Questionable Correspondence Questionable Publication Package ‘1 Legal, Special, or Media Correspondence Other

Inmate’s Signature_______________________ Date

Notifying Officer’s Signature ‘i, . fl 121 ( Original—Return to unit mail room. Copy—Give completed copy to inmate. I-152