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LLS Time Account Change Request <br />FARGO ECFIV h <br />Cantdnn 1- CustnniAr and At4 --mmf Mfnrmwlfnn v gm <br />❑ Credit Principal (TA) ❑ Check ICO) ❑ Credit Checking ITT) ❑ Credit Savings ITT) <br />❑ Checkkrg <br />❑ savings . <br />❑ Internal /Zero 671 or blank) <br />❑ Extemal <br />❑ Monthly (IM) ❑ Quarterly 110) ❑ Semi - Annual I/S) ❑ Annual #Y) ❑ At end of term /f term = 12 months or less )00) <br />Add Trade A-Rate option ❑ - _..._ _.. _......� .. -•- • . Effective date date interest Rate <br />t !Time Account(Sav /n s Cert catea only) <br />AmitrAmount <br />Funds o9bursed to me by: <br />❑ A new One account Number S <br />❑ An offkial check Number <br />S <br />❑X Credit to account Number 7061862501 $ 56, 345.00 <br />Section 7: Customer Stpnatwe <br />I authorize the Bank to make the above changes to my time account. The Bank will automatically renew my time account at maturity <br />unless /notify the Bank otherwise. If the change Includes a new term, 1 acknowledge receipt of and agree to the applicable account <br />agreement and the applicable fee and information schedule. <br />x I -- <br />ST TE OF COLORADO <br />STATE OF COLORADO <br />MINED LAND RECLAMATION BOARD <br />e W <br />Account <br />3 <br />84076 369 <br />RE NCIG FINANCIAL <br />AeWtrmenr p d eoeount reueber <br />1313 SHERMAN ST RM 215 <br />DENVER CO 80203 2243 <br />Seradon 2 Amended Terms M Renewef (Complete Section 6 when <br />funds are withdrawn) !Tune AccounwRetlrement <br />Accounts only) <br />w term <br />A4&W&" <br />MWIRntenrear <br />MAM&W rote <br />nW-AW (ToW Account oery ) <br />e Accent a* 30811 <br />Mew veA,e <br />bftcefft date <br />❑ Credit Principal (TA) ❑ Check ICO) ❑ Credit Checking ITT) ❑ Credit Savings ITT) <br />❑ Checkkrg <br />❑ savings . <br />❑ Internal /Zero 671 or blank) <br />❑ Extemal <br />❑ Monthly (IM) ❑ Quarterly 110) ❑ Semi - Annual I/S) ❑ Annual #Y) ❑ At end of term /f term = 12 months or less )00) <br />Add Trade A-Rate option ❑ - _..._ _.. _......� .. -•- • . Effective date date interest Rate <br />t !Time Account(Sav /n s Cert catea only) <br />AmitrAmount <br />Funds o9bursed to me by: <br />❑ A new One account Number S <br />❑ An offkial check Number <br />S <br />❑X Credit to account Number 7061862501 $ 56, 345.00 <br />Section 7: Customer Stpnatwe <br />I authorize the Bank to make the above changes to my time account. The Bank will automatically renew my time account at maturity <br />unless /notify the Bank otherwise. If the change Includes a new term, 1 acknowledge receipt of and agree to the applicable account <br />agreement and the applicable fee and information schedule. <br />x I -- <br />