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FIRST STATE BANK OF COLORADO <br />PD BOX 38 -�� <br />HOTCHKISS, COLORADO 81419 <br />(970) 872 -3111 <br />EDWARD M YAKLICH <br />STATE OF COLORADO /MLRB, <br />1313 SHERMAN STREET ROOM 215 <br />DENVER CO 80203 <br />PAYER'S NAME, STREET ADDRESS, CITY OR TOWN, PROVINCE OR STATE, COUNTRY, ZIP OR FOREIGN POSTAL CODE, <br />PIR-S 1015TIATE BANK OF COLORADO <br />IMPORTANT: <br />Form 1099 -INT <br />PO BOX 38 <br />This Is important tax Information and is <br />being furnished to the Internal Revenue <br />Interest Income <br />H O T C H K I S S COLORADO <br />Service. If you are required to file <br />(97 0) 872-3111 <br />return, a negligence penalty or other <br />sanction may be Imposed on you If this <br />Copy B / For Recipient <br />income is taxable and the IRS determines <br />it has not been reported. <br />Department of the Treasury - Internal Revenue Service <br />ACCOUNT NUMBER <br />DESCRIPTION <br />1. INTEREST INCOME <br />2. EARLY HDRAWAL <br />3 U.S. SAVINGS BOND S <br />4 INCOME TAX <br />15 WITHHELD <br />PENALTY <br />TREASURY OBLIGATIONS <br />WITHHELD <br /> <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. 1750 <br />17.5 0 <br />D 0 <br />3. <br />4. <br />15. <br />.00 <br />telephone us at the number listed. <br />PAYER'S FEDERAL IDENTIFICATION NUMBER <br /> <br />RECIPIENT' <br /> <br />5. INVESTMENT EXPENSES <br />16. FOREIGN TAX PAID <br />7. FOREIGN COUNTRY OR U.S. POSSESSION <br />Vold Corrected 2nd TIN Notice <br />6. TAX-EXEMPT INTEREST <br />1 9. 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 />RECIPIEp�NpTpS NAME, STREET ADDRESS (INCLUDING APT. NO.), CITY OR TOWN, PROVINCE OR STATE, COUNTRY, <br />AHB b W H fM.IGy Plen rTt r/D TELEPHONE NO. <br />STATE OF COLOORAfDlO /MLRB, <br />1313 SHERMAN STREET ROOM 215 <br />Interest Income <br />DENVER CO 80203 <br />1 Copy B / For Regent <br />PAGE 1099 -INT - <br />OMB 1545 -0112 (keep for your records) www irs.gov/form1099int <br />