Acknowledgment of Cancellation Request - Theresa Kasprzyk 2021-07-27SfateArmvS-t'ate Farm General Insurance Company
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PO Box 853925
Richardson, TX 75085-3925
AT1
M-23-1121-FC18 U F
006135 0005
THE COSTA MESA SANITARY
DISTRICT ITS ELECTED &
APPOINTED OFFICIALS AGENTS
OFFICERS VOLUNTEERS & EMPLOYEE
290 PAULARINO AVE
COSTA MESA CA 92626-3314
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Office
POLICY NUMBER: 92-CF-N648-5
DATE CANCELED: JUL 27 2021
RETURN PREIIIIUM: None
To:[:] INSURED F1 MORTGAGEE R OTHER
•
COsta,N4esa ,iaajta[,.y illstrIct
Dear Policyholder,
As requested, this policy has been canceled effective 12:01 a.m. (or the time which is required by state law) as of the Date
Canceled shown above. We thank you for giving us the opportunity to provide this insurance.
Insured:
KASPRZYK,THERESA
DBA TERRASTAR MEDIA
Agent: MARK REESE CLU
Telephone: (714) 895-3022
01
Location:
13861 JASPERSON WAY
WESTMINSTER CA
92683-4012
I • 0 0
6135 AIN
537-147.12 09-11-2013 (olf3122g)
001