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680 (9-62)
PRTD. IN U.S.A.

R E A EXPRESS

UNIFORM BLANK FOR PRESENTATION OF LOSS AND DAMAGE CLAIMS 
Claimants are requested to make use of this form for filing claims with R E A Express. Please type or print. 

Date May 25, 1967  1967
Supt's Div. No. 
Office Code No.  
Claimant's Claim Number
(Claimant) Leo Castelli Gallery (Local Address of Claimant) 4 East 77th Street (City & State) New York, New York

This claim for $1000.00 is made against R E A EXPRESS for (Loss or Damage) Loss to shipment. 

Addressed to (Consignee) x Washington Gallery of Modern Art No. 1503 21st Street N.W. Street 

At x Washington, D.C.  Express to (If destination not an express office)  the above address 

Shipped by (Shipper) x William Rockhill Nelson Gallery of Art Atkins Museum of Fine Arts No. 4525 Oak Street Street 

From (Insert Actual Shipping Point or Express Office) x Kansas City, Missouri 64111 Shipped (Date) April 20 1967

Receipt No. (Prepaid or [[strikethrough]] Collect [[/strikethrough]]) AE - 49 - 22 - 31 ARTICLE (Shipping cont.) crated sculpture Pieces two Weight 760 lbs.

Date of advice from Consignee of non-delivery, shortage or damage, if any, copy attached see rpt.

DETAILED STATEMENT SHOWING HOW AMOUNT CLAIMED IS DETERMINED
(Number and description of articles, nature, and extent of loss or damage, invoice price of articles, amount of claim, etc.)

2 / One piece of sculpture, made of aluminum and 
plexiglass, damaged beyond repair. Value : $1000.00
This is one of four pieces of sculpture contained in two wooden crates; it will be necessary to replace the piece. :
TOTAL AMOUNT CLAIMED: $1000.00

IN ADDITION TO THE INFORMATION GIVEN ABOVE, THE FOLLOWING DOCUMENTS SHOULD BE SUBMITTED IN SUPPORT OF THIS CLAIM*

(x) 1. The original, photostat or exact copy of the Express receipt issued to the shipper.
(x) 2. Original invoice or certified copy.
( ) 3. In case of loss give complete description by which articles can be identified. If castings or parts submit catalog cut or sketch. 
( ) 4. Complaint received from consignee when claim is filed by shipper.
( ) 5. Copy of Joint Inspection Report furnished consignee in case of damage.

REMARKS: 
I have read the information appearing on the reverse side of this form and the foregoing statement of facts is hereby certified as correct.

X Kay Bearman for Leo Castelli
(Signature of Claimant)
By

This claim is to be settled with the Leo Castelli Gallery
4 East 77th Street New York, New York

*Claimant will please place check (x) before such of the documents mentioned as have been attached and explain under "Remarks" the absence of any documents called for in connection with this claim.
NOTE: If claim is to be settled with another party, so authorize under "Remarks."

Transcription Notes:
Unsure re the signature at the bottom. Kay Bearman has signed other documents related to this claim.