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Roup for This Box 1 2 3 4 5 6 7 6. Date First Period Effective 5. Size of Box Held by Customer 1 2 3 4 5 7. Date Box Surrendered 8. Remarks 9. Current Semi-Annual Fee for This Box 10. Current Combination or Serial No. of Key(s) PS Form 1091-A, September 2002 Amount Date Periods 6 Mo. 12 Mo. Next Due Date Empl. Inits. List Changes of Address (Cross out old address when new address is entered) PS Form 1091-A, September 2002 (Reverse).

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