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<br />',., <br /> <br />y <br /> <br />Agency 10 P J)A _ <br />.. <br />iJ:"" l?NRJl.ccr- SANf>\flxmN. 'l( 5'710 <br />, .' '. 'STAT"EOF COLp,RAD,O . (;W6f3-JAN tLLI M )/,34h'2.. <br />" . AUTHORIZATION AGRl::EMENT <br />. '. FOR AUTOMATIC DEPOSITS (ACH CREDITS) <br /> <br />I (we) ~erebY authorize the Department of NATURAL 1<e.~llR(lf=. 0. ,State of Colorado, <br />hereinafter called STATE. to Initiate credit entries, and if necessary, debit entries and adjuslments for any credit entries in error to <br />our bank account Indicated below and the Bank named below. hereinafter called OEPOSITORY. to credit and/or debit the same to <br />such account. . <br /> <br />".7 <br />~/ . <br /> <br />APPLICATION (Payment Type) <br /> <br />ENTITY NAME <br /> <br />FEDERAL E.I.N. NUMBER <br /> <br />ADDRESS: <br /> <br />BUILDING <br /> <br />STREET <br /> <br />CITY, STATE, ZIP <br /> <br />DEPOSITORY NAME <br /> <br />BRANCH <br /> <br />ADDRESS: <br /> <br />BUILOING <br /> <br />STREET <br /> <br />CITY, STATE, ZIP <br /> <br />DEPOSITORY TRANSIT NUMBER <br /> <br />DEPOSITORY ACCOUNT NUMBER <br />. CHECKING [K] <br /> <br />(I..Jv(]fS I OAIJ..J)/5.$IJPJ3:.E HFJJI& <br />\ ' n <br />y/, c.v---k.-'l/ tj UA~lj~' <br />'B'";i:-l :J..L:l '7c) ~ <br />3.599'7 ,,(.'/;'/73 /.", <br /> <br />,...., <br />= <br />= <br />...... <br />= <br />" <br />-< <br />....... <br /> <br />a J -1/1. rTiUf C ~\ >(/) 7 .3.3 <br />J <br /> <br />Ao /V~{" 1\-1 fi (JLt~Ui.Ai() - <br /> <br />z <br />~O'. <br />_cm <br />~::o -u <br />''':1>>. <br />.-. :,g <br />01. -t <br /><=:::03: <br />ZITI,..., <br />l...l:Z: <br />zo--{ <br />C <br />(;)::00 <br />C"')t"1 <br />,..., <br />c.n <br /> <br />s:- <br />eT> <br /> <br />v <br />:x <br /> <br />'..' <br /> <br />$, .J /I d'. -L 0<>.-1-, J t;:" f; <br /> <br />.~.(>~. Yo7~-1 <br />, <br /> <br />I () 7 /)0 ~ /J.t.j.f3 <br />w501J{)()rn 7 <br /> <br />~AVINGS D <br /> <br />{P1etJ$e attach one (l)Voi cI eel c..hec.k. ) <br /> <br />This agreement is to remain in full force and effect until the STATE has received written notification from the ENTITY of its <br />termination in such time and inanner to afford STATE and DEPOSITORY a reasonable opportunilyto act on it. It is the responsibility <br />. of the ENTITY to fill out a new agreement if the ENTITY changes banks or accounts. <br /> <br />. 9HllHnO::JJ'V <br />S3:ll:lnOS3l:11'Vl:Inl'vN <br />30 IN3Wll!Vd30 <br /> <br />SO:8 Wd I 8130 EOOl <br /> <br />Date <br /> <br />If) /.;J.? h~ Phone No. :if1/7-3~t? '9 <br />/ / <br />'n]~A-If ~ l~iu~J <br />. ;tJ' <br /> <br />,- <br /> <br />Authorized Signature <br /> <br />Tiile <br /> <br />Authorized Signature <br /> <br />Title <br /> <br />DISTRIBUTION: WHITE" Accounts & Control CANARY" Agency PINK. Entity <br />