EFTA00005284-p-74.jpg

The image shows a printed form with text and instructions on it. At the top of the form, there is a bold statement saying "NOT SCANNED." Below this statement, there is additional text which seems to be handwritten, but it's not entirely clear due to the quality of the image. The bottom part of the form includes more printed text and appears to have instructions for someone named "Terry." The background behind the form is not clearly visible, focusing instead on the document itself. There are no people or locations discernible from this image.