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• <br /> i (9/6 M 14 F5-0a5 <br /> FIRST SOUTHWEST BANK ACCOUNT NUMBER PORTFOUO NUMBER <br /> 350007899 400290 <br /> 2060 E Highway 112 <br /> - Center CO 81125, <br /> ACCOUNT OWNER(S)NAME&ADDRESS <br /> GARY C BOYCE <br /> OWNERSHIP OF ACCOU%T • CONSUMER(Select One and Initial): RANCHO ROSADO <br /> ®. Single-Party Account Mi [7] Trust-Separate Agreement ASSIGNED TO ST OF COLMLRB <br /> ❑ Multiple-Party Account rJ <br /> ❑ Other <br /> RIGHTS AT DEATH (Select One And Initial): 1313 SHERMAN STREET RM 215 <br /> ® Single-Party Account DENVER CO 80203 <br /> ❑ Multiple-Party Account With Ight of Survivorship <br /> ❑ Multiple-Party Account Without Right of Survivorship ❑ NEW IN EXISTING <br /> ❑ Single Party Account With Pay On Death TYPE OF ❑ CHECKING ❑ SAVINGS <br /> El Multiple-Party Account With Fight of Survivorship ACCOUNT <br /> and Pay On Death ❑ MONEY MARKET x❑ CERTIFICATE OF DEPOSIT <br /> PAY-ON-DEATH BENEFICIARIES:To Add Pay-On-Death Beneficiaries Name One or More: ❑ NOW ® PUBLIC FUNDS <br /> This is your(check one): <br /> ❑ Permanent ❑ Temporary account agreement. <br /> Number of signatures required for withdrawal <br /> FACSIMILE SIGNATURE(S)ALLOWED? ❑ YES ❑ NO <br /> X <br /> ] <br /> OWNERSHIP OF ACCOUNT-BUSINESS PURPOSE SIGNATURE(S) - The undersigned certifies the accuracy of the <br /> information he/she has provided and acknowledges receipt of a <br /> ❑ SOLE PROPRIETORSHIP ❑ PARTNERSHIP completed copy of this form. The undersigned authorizes the <br /> ❑ CORPORATION: Ill FOR PROFIT 1=1 NOT FOR PRT financial institution to verify credit and employment history and/or <br /> have a credit reporting agency prepare a credit report on the <br /> ® PUBLIC FUND-PDPA 010004005101 undersigned, as individuals. The undersigned also acknowledge the <br /> BUSINESS: receipt of a copy and agree to the terms of the following <br /> COUNTY&STATE agreement(s)and/or disclosure(s): <br /> OF ORGANIZATION: _ ® Terms & Conditions ® Truth in Savings ® Funds Availability <br /> AUTHORIZATION DATED: ® Electronic Fund Transfers ® Privacy ❑ Substitute Checks <br /> ❑ Common Features ❑ <br /> DATE OPENED 04/22/1994 BY 0 � r /----- <br /> ] <br /> INITIAL DEPOSIT$ 0.00 <br /> ❑ CASH CI CHECK ❑ (1) X ,i* / <br /> HOME TELEPHONE# e+- "" B b <br /> BUSINESS PHONE# I.D.# 521-60-5697 D.O.B. 04/13/1961 <br /> DRIVERS LICENSE# <br /> E-MAIL <br /> (2): [ <br /> 9 61%/2/.' r� "�/, <br /> -1 <br /> EMPLOYER X <br /> MOTHERS MAIDEN NAME LORETTA E PINEDA . <br /> Name and address of someone who will always know your location: I.D.# D.O.B. <br /> (3): X r" �a� <br /> BACKUP WITHHOLDING CERTIFICATIONS (t <br /> TIN:521-60-5697 I.D.# D.O.B. \ SON <br /> ® TAXPAYER I.D.NUMBER-The Taxpayer Identification Number shown above(TIN) W <br /> is my correct taxpayer identification number. N0�<,�GSg <br /> ® BACKUP WITHHOLDING-I am not subject to backup withholding either because I (4): X \�S\0 G 0 <br /> have not been notified that I am subject to backup withholding as a result of a failure to p M�N\N <br /> report all interest or dividends,or the Internal Revenue Service has notified me that I am <br /> no longer subject to backup withholding. <br /> CIEXEMPT RECIPIENTS -I am an exempt recipient under the Internal Revenue I.D.# D.O.B. <br /> Service Regulations. AGENCY (POWER OF ATTORNEY) DESIGNATION (Optional): To Add <br /> SIGNATURE: I certify under penalties of perjury the statements checked in this Agency Designation To Account, Name One or More Agents: <br /> section and that I am a U.S. citizen or other U.S. person (as defined in the <br /> i <br /> instr ). <br /> ,r // (Select One and Initial): <br /> X • / El Agency Designation Survives Disability or Incapacity of Parties <br /> - .o I. 41= 1 it (Date) ❑ Agency Designation Terminates on Disability or Incapacity of Parties <br /> Signature Card-CO MPSC-LAZ-CO 10/1/2009 <br /> Bankers SystemsTM <br /> Wolters Kluwer Flnanciai Services ©1992,2009 Page 1 of 1 <br />