**Document Title:**

The document appears to be an insurance endorsement or premium breakdown agreement.

**Content:**

- **Date:** 5/21/81
- **Premium Breakdown for Period from 5/21/81 to 5/21/82:**
  - 179,854 U.S. Funds
  - 6,446 Canadian Funds

- **Other Terms and Conditions of Insurance Remain Unchanged.**

**Signatures:**

- **President:** John A. [Last Name]
- **Authorized Representative:** George [Last Name]

**Additional Notes:**

- The document includes a stamp and some text that is partially obscured.
- There is a reference to "GJQ: sh" and "4/29/81," which might indicate a file or record reference number and date.

**Endorsement:**

The document is marked as an endorsement, indicating it is supplementary information attached to the policy.