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FIRST STATE BANK OF COLORADO <br />PO BOX 38 <br />HOTCHKISS, COLORADO <br />(970) 872 -3111 <br />EDWARD M YAKLICH <br />STATE OF COLORADO /MLRB, <br />1313 SHERMAN STREET ROOM 215 <br />DENVER CO 80203 <br />81419 <br />Vrn l a gq-oZ � <br />i 2 r1" A 1 1 <br />PAYER'S NAME, STREET ADDRESS, CITY OR TOWN, PROVINCE OR STATE, COUNTRY, ZIP OR FOREIGN POSTAL CODE, <br />�4F€j;Ej1'SdiTE BANK OF COLORADO <br />IMPORTANT <br />Form 1099 -INT <br />PO BOX 38 <br />being furnished to the Internal Revenue <br />Interest Income <br />H O T C H K I S S, COLORADO 81419 <br />Service. If you are required to file <br />realm, a negligence penalty or other <br />a <br />(9 7 0) 872-3111 <br />sanction may be Imposed on you N this <br />Copy B / For Recipient <br />Income Is taxable and the IRS determines <br />R has not been report ed. <br />Department of the Treasury - Internal Revenue Service <br />ACCOUNT NUMBER <br />- - <br />' DESCRIPTION ." <br />1. INTEREST INCOME <br />- <br />2. EARLY =' . <br />- °=.WITHDRAWAL _ <br />3. ANTEREST.ON -_ : -- -. "; <br />U. &SAVINGS ttONDa :,+ <br />'FEDERAL -_ <br />- INCOME TAx <br />15..STATE TA7(_ <br />. - wmtHELD - <br />- - <br />- <br />- - <br />- ,PENALTY <br />sTREASURY•OBI.IGATa>IR3 <br />•WITHHELD <br />- - <br />003300027070 <br />TIME DEPOSIT <br />17.50 <br />If you have any questions about this statement <br />you may write us at the address listed above or <br />TOTALS �_ <br />1. <br />17, 50 <br />2. <br />-:'00- <br />3. <br />: 00 <br />: UQ ; <br />15. <br />.'00 <br />telephone us at the number listed. <br />PAYER'S FEDDE� N NUMBER <br /> NUMBER <br />5. INVESTMENT EXPENSES <br />16. FOREIGN TAX PAID <br />7. FOREIGN COUNTRY OR U S. POSSESSION <br />Void Corrected 2nd TIN Notice <br />6. TAX -DEMPT INTEREST <br />19. SPECIFIED PRIVATE ACTIVITY BOND INTEREST <br />12. TAX - EXEMPT BOND CUSIP NO <br />13. STATE <br />-- - - <br />14. STATE IDENTIFICATION NO <br />- - - - - - - - - - - - - - - - - - - - - - - - - <br />CODES <br />10. MARKET DISCOUNT <br />11. BOND PREMIUM <br />NAME, STREET ADDRESS (INCLUDING <br />NO. .), CITY OR TOWN, PROVINCE OR STATE, COUNTRY, <br />ARECIPIENrS <br />D TELEPHONE <br />STATE OF COLORADO /MLRB, <br />1313 SHERMAN STREET ROOM 215 <br />DENVER CO 80203 <br />Interest Income <br />1 Copy B / For ReFMRnt <br />PAGE 1099 -INT - <br />OMB 1545 -0112 (keep for your records) www.irs.gov1form1099int <br />