PROJ01960 ‎(2)‎

• Contract/PO #: C150249
• Contractor Name: Black Dike Pipeline Company
• Contract Type: Loan
• Water District: 0
• County: Montezuma
• Loan Projects - Doc Type: Feasibility Study

I,

I

12. The nonprofit corporation is formed under the Colorado Revised Nonprofit Corporation Act.

1

13. The corporation will 0 OR will not 0 have voting members.

14. A description of the distribution of assets upon dissolution is attached. ,

1

15. Additional information may be included pursuant to 97-122-102, C.R.S. and other organic statutes. If
applicable, mark this box 0 and include an attachment stating the additional information.

I

Notice:

I

Causing this document to be delivered to the secretary of state for filing shall constitute the affirmation or
acknowledgment of each individual causing such delivery, under penalties of perjury, that the docume:nt is the
individual's act and deed, or that the individual in good faith believes the document is the act and deed of the
person on whose behalf the individual is causing the document to be delivered for filing, taken in conformity
with the requirements of part 3 of article 90 of title 7, C.R.S., the constituent documents, and the organic
statutes, and that the individual in good faith believes the facts stated in the document are true and the
document complies with the requirements ofthat Part, the constituent documents, and the organic statutes.

I

I

This perjury notice applies to each individual who causes this document to be delivered to the secretary of
state, whether or not such individual is named in the document as one who has caused it to be deliven:d.

I

16. Name(s) and addressees) of the
individual(s) causing the document
to be delivered for filing:

Welch

Penny
(First)

Kathleen
(Middle)

(SuffIX)

(Last)
14575 Road G

1

(Street name and number or Post Office Box information)

Cortez

(City)

CO 81321-9575
(State) (PostallZip Code)
United States
(Country - if not US)

I

(Province - if applicable)

1

(The document need not state the true name and address of more than one individual. However, if you wish to state the name and address

of any additional individuals causing the document to be delivered for filing, mark this box 0 and include an attachment slating the
name and address of such individuals.)

Disclaimer:

I

I

This form, and any related instructions, are not intended to provide legal, business or tax advice, and are
offered as a public service without representation or warranty. While this form is believed to satisfy minimum
legal requirements as of its revision date, compliance with applicable law, as the same may be amended from
time to time, remains the responsibility of the user of this form. Questions should be addressed to th{: user's
attorney.

I

I

I

I

ARTINC_NPC

Page 3 of3

R,:v, 11/16/2005

I