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Appendix D <br /> Annuity <br /> CERTIFICATE OF ENTITY OWNERSHIP <br /> Prudential Financial <br /> The Prudential inauranca Company of America <br /> Prue()Lilo Insurance Company of New Jersey <br /> Pre the Insurance Company <br /> AP are Prudsntal financial Conyoaniss <br /> Instructions(Please print or type): <br /> • Completion of this form is required when an entity is to own an annuity,when there is a change of ownership to an entity,or <br /> when an entity is making a claim for a Death Benefit as a Beneficiary. <br /> • If Beneficiary making a claim for a Death Benefit uses this form,any reference to"Owner"shall mean"Beneficiary"and any <br /> reference to"ownership rights^shall mean the rights available to a Beneficiary under the terms of the Contract_ Nothing in this <br /> document should be construed as granting a Beneficiary the rights afforded to an Owner under the Contract. <br /> I. ENTITY INFORMATION: Prudential's Annuity Products cannot be sold Is entitles sited outside Oche United States. <br /> ENTITY'NAME ANNUITY NUMBER <br /> MONTEZUMA VALLEY IRRIGATION COMPANY <br /> ENTITY SITUS(CITY,STATE/ Dart oroacar,tuTrri TAX ID NUMBER <br /> eiCOPPORATIOu <br /> 11501 HWY 491 CORTEZ, CO 81321 5151)9w 640270210 <br /> Required: <br /> Is this entity primarily in the business of Investing,reinvesting,owning,holding or trading in securities? <br /> ❑ <br /> yes Q No <br /> If Yes then please provide specifics: <br /> 2. POWER OF THE INDIVIDUALS AUTHORIZED TO ACT ON BEHALF OF THE ENTITY <br /> The document andior agreement creating and/or organizing the above entity,if applicable,is referred to herein as the"Entity <br /> Agreement." <br /> (a)Is there more than one authorized individual named in the entity agrcemem? <br /> ❑ No <br /> ❑ Yes If Yes,then all authorized individuals must sign this certificate. <br /> (b) If there is more than one Authorized Individual named in the Entity Agreement,does the Entity Agreement expressly provide that <br /> each of the Authorized Individuals can act individually,independently,and without the consent of the other individuals authorized <br /> to act on behal f of the Entity? <br /> ❑ No <br /> ❑ Yes lfycs,by signing this Certificate the authorized individuals hereby certify that Prudential is authorized to <br /> follow the instructions of any one Authorized Individual. If no,Prudential will require the signatures of all <br /> Authorized Individuals to conduct any transaction on the annuity contract. <br /> (c) The undersigned Authorized Individuals hereby certify that we have the power under the Entity Agreement or otherwise to enter <br /> into transactions for the purchase of annuities,as well as the exercise of all ownership rights under the annuity. <br /> 3.IMPORTANT TAX INFORMATION-REQUIRED <br /> This section only applies to non-qualified deferred annuities. <br /> A)Is this a tax-exempt entity as described under sections 50l(03),501(c)(9),or 401(3)of the internal Revenue Code? <br /> O No <br /> x Yes Wynn checked yes,thee go to text page.Pans B and C do not apply <br /> B)Is this a grantor trust for federal income tax purposes as described under IRC Sections 671-679? <br /> C No <br /> ❑ Yes Name of the Grantor Type of trust ❑Revocable ❑lrrevocabk <br /> Grantor's Date of Birth Grantor's Social Security number <br /> (If you checked yes,complete the above information,then go to next page.Part C des nor apply) <br /> C)Is this entity acting as an agent for an individual under IRC Section 72(u)? <br /> ❑No (Cbarliable trims(including charitable remainder artenni,corporations,limited liability companies,and partnerships must check'No'.) <br /> O Yes <br /> — <br /> Control Prudential Annuity Semitic Center at I>BTS•778-2886 or'stviv nneb ntiulitxn <br /> Piesst return err fax form m Pndentad Annuity Senict Caner,P O Thad 7960,Philadctpaw,PA 19176 Fax(1IX11 576.1217 <br /> For OscmiE a IkliKm Prudential Manny Service Cana,2101 Welsh Road.Dresher.PA 19025 <br /> ORD 036*11(0e06) Page 1(11'2 <br /> 33 <br />