Form of the accompanying address to a valuable parcel at the sum of 800 rubles. Weight: 37,30 pounds, with cash on delivery at the sum of 500 rub. It was sent from Odessa to Shargorod on June 07, 1919, received on June 10, 1919. RSFSR tax: weight tax 16,50 rub.+ 2% for cash on delivery = 10 rub., value insurance - 4,0 rub. Total payment should be 30,50 rub. Form is franked with: Russian Empire stamps with trident overprint, (Odessa 6) 3,5 rub. - 4 pcs. Russian Empire stamps 1 rub. - 2 pcs. with trident overprint (Odessa 6), Russian Empire stamp 50 kop. with trident overprint (Odessa 2) and UNR stamp 50 shagiv = 0,25 rub. Totally: 16,75 rub. Postal worker did a mistake at 13,75 rub. The accompanying address to a valuable parcel, with cash on delivery paid with UNR stamps, Russian Empire stamps with UNR trident overprints (according to RSFSR tax), with a mistake of post worker at large sum - is a very rare form.