One leaf typewritten on the front side. The document is in good physical condition. The document was laminated. There are lamination-related creases on the document. Both upper corners were folded into the laminate. There are two minor tears at the upper edge. There is a significant tear at the middle left edge. There are two minor tears at the lower left edge. There is a minor tear at the right lower edge. There are stains of unknown origin throughout the document. The document was folded horizontally and vertically into sixths, possibly for mailing. The informant citation is handwritten in pencil at the lower right corner.