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Substitute Form REQUEST FOR TAXPAYER IDENTIFICATION State of Colorado <br /> W-9 • NUMBER (TIN) VERIFICATION • Do NOT send to IRS <br /> PRINT OR TYPE <br /> Legal Name (OWNER OF THE EIN OR SSN AS NAME APPEARS ON IRS OR SOCIAL SECURITY ADMINISTRATION RECORDS) RETURN TO ADDRESS BELOW <br /> DO NOT ENTER THE BUSINESS NAME OF A SOLE PROPRIETORSHIP ON THIS LINE-See Reverse for Important Information <br /> c <br /> Rio Grande Water Conservation District 3;*t=, ,W <br /> Trade Name COMPLETE ONLY IF DOING BUSINESS AS(D/B/A) + rn C <br /> Well Rehabilitation Fund <br /> Co <br /> Remit Address <br /> 10900 U.S. Highway 160 East Alamosa, Colorado 81101 • m <br /> =a. <br /> Purchase Order Address—Optional PART II See Part nstructi u, n Back of Form <br /> tv <br /> Check legal entity type and enter 9 digit Taxpayer Identification Number(TIN)below: Do Not enter an SSN or GIN that was not <br /> (SSN=Social Security Number EIN=Employer Identification Number) assigned to the legal name entered above. <br /> Individual (Individual's SSN) _ — <br /> NOTE:If no name is circled on a Joint Account when there is more than one name,the number will be considered to be that of the first name listed. ——— —— ———— <br /> Sole Proprietorship(Owner's SSN or Business FEIN) SSN <br /> NOTE:Enter both the owner's SSN and the business EIN(if you are required to have one) ——— —— ———— <br /> EIN <br /> Partnership n General n Limited (Partnership's EIN) _ <br /> —— <br /> Estate/Trust (Legal Entity's EIN) _ <br /> NOTE:Do not furnish the identification number of personal representative or trustee unless the legal entity itself is not designated in —— <br /> the account title.List and circle the name of the legal trust,estate or pension trust. <br /> Other ■ (Entity's EIN) — <br /> Limited Liability Company,Joint Venture,Club,etc. —— <br /> Corporation Do you provide medical services? Yes n No (Corp's EIN) _ <br /> Includes corporations providing medical billing services <br /> lx Government(or Government Operated)Enity (Entity's EIN) _ n h (.$.4_5_7 <br /> Organization Exempt from Tax under Section 501(a)— (Org's EIN) — <br /> Do you provide medical services? E]Yes Ei No —— <br /> Check Here if you do not have a SSN or EIN, but have applied for one. See reverse for information on How to Obtain A TIN. <br /> Licensed Real Estate Broker? ❑Yes n No <br /> Under Penalties of perjury,I certify that: <br /> (1) The number listed on this form is my correct Taxpayer Identification Number(or I am waiting for a number to be issued to me)AND <br /> (2) I am not subject to backup withholding because: (a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue <br /> Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends'or(c)the IRS has notified me that I <br /> am no longer subject to backup withholding(does not apply to real estate transactions,mortgage interest paid,the acquisition of abandonment of <br /> secured property,contribution to an individual retirement arrangement(IPA),and payments other than interest and dividends). <br /> CERTIFICATION INSTRUCTIONS — You must cross out item(2)above if you have been notified by the IRS that you are currently subject to backup <br /> withholding because of under reporting interest or dividends on your tax return.(See Signing the Certification on the reverse of this form.) <br /> THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS <br /> DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING <br /> Ralph G. Curti , J General Manager <br /> NAME(Print or Type) p __ � TITLE (Print or Type) g <br /> AUTHORIZED SIGNATURE d''f� �� DATE 9,7 0o'Z PHONE(r. ) 6-9f-40"/ <br /> DO NOT WRITE BELOW THIS LINE RETURN BOTH COPIES TO ADDRESS ABOVE <br /> AGENCY USE ONLY <br /> Agency_ _ _ Approved By Date <br /> 1099 Y N <br /> VEND Addition Change _ Action Completed By Date <br /> 815-82-50-7093(R 4/97) <br />