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Date Tax Opened: 04/09/2015 Term: 60 Months ID:84-0410936 Number: 100601 CERTIFICATE OF DEPOSIT COPY AND CERTIFICATE OF DEPOSIT SIGNATURE CARD Account Number: 56423 Dollar Amount of Deposit: Fifteen Thousand Dollars And No Cents $15,000.00 _ This Time Deposit is Issued to: Issuer: INTEGRITY BANK&TRUST CHILCOTT DITCH CO 1275 VILLAGE RIDGE POINT 1845 WOODMOCR DR MONUMENT,CO 80132 MONUMENT CO 80132 Not Negotiable-Not Transferable-Additional terms are below. By CERTIFICATE COPY Additional Terms and Disclosures This form contains the terms for your time deposit. It is also the Minimum Balance Requirement: You must make a minimum deposit to Truth-in-Savings disclosure for those depositors entitled to one. There are additional terms and disclosures on page two of this form, some of this this account of$500.00 which this form explain or expand on those below. You should keep one copy of ® You must maintain this minimum balance on a daily basis to earn the Maturity Date:This account matures 04/09/2020 annual percentage yield disclosed. (Sec below for renewal information.) Withdrawals of Interest: interest ❑ accrued ❑ credited during a Rate Information: The interest rate for this account is 1.40% term can be withdrawn: with an annual percentage yield of 1.41 %.This rate will be paid until the maturity date specified above, interest begins to accrue on Early Withdrawal Penalty: If we consent to a request for a withdrawal the business day you deposit any noncash item(for example, a check). that is otherwise not permitted you may have to pay a penalty. The Interest will be compounded . penalty will be an amount equal to:six months of Interest Interest will be credited by check Quarterly interest on the amount withdrawn. ® The annual percentage yield assumes that interest remains on deposit Renewal Policy: until maturity. A withdrawal of interest will reduce earnings. ❑ Slagle Maturity: If checked, this account will not automatically ❑ If you close your account before interest is credited, you will not renew. Interest ❑ will ❑ will not accrue after maturity. receive the accrued interest. ® Automatic Renewal: If checked, this account will automatically The NUMBER OF ENDORSEMENTS needed for withdrawal or any renew on the maturity date. (see page two for terms) other purpose is: one Interest lig will ❑ will not accrue after final maturity. ACCOUNT OWNERSHIP:(select one and initial) ❑ Single Party Account TIN:84-0410936 ❑ Multiple Party Account Social Security or Employer's LD. Number: Under ❑ Trust-Separate Agreement dated: penalties of perjury I certify that the above number is my 0 co, ect Taxpayer Identification Number. w Rights at Death:(select one and initial) X_ "•cPF ❑ Single Party Account Ba'Tup Withholding-Under penalties o perjury I certi ❑ Multiple Party Account with Right of Survivorship that I am a U.S. person (including a U.S. resident alien and that I am not subject to backup withholding, either ❑ Multiple Party Account without Right of Survivorship because I have not been notified that I am subject to backup ❑ Single Party Account with Pay on Death withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Service has notified me ❑ Multiple Party Account with Right of Survivorship and Pay on Death that I am no longer sub' 'to bac p withholding. Pay On Death Beneficiaries:To add Pay On Death Beneficiaries' X ° RATE Rfr i d5T name one or more: L__ SIGNA URES:I AQfiEE TO i IE T 'MS ATED ON PAGE ONE AND PAGE TWO. .e? IX Ever Evertigf 01993 Bankers Systems,Inc.,St.Cloud,MN Form CO-AM-AZ-CO(2) 11/112011 READ PAGE TWO FOR ADDITIONAL TERMS (page 1 of 2)