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DR 1083(09/96) <br /> Colorado Department of Revenue <br /> 1375 Sherman Street <br /> Denver,Colorado 80261 <br /> INFORMATION WITH RESPECT TO A CONVEYANCE <br /> OF A COLORADO REAL PROPERTY INTEREST <br /> 1. Name(s)and address of transferor(s) OWENS BROS.CONCRETE CO.,A <br /> COLORADO CORPORATION. <br /> 2. Transferor is(check one) _individual _estate _ _other(specify) <br /> _xxx_corporation trust a Colorado limited liability limited partnership <br /> 3. Social Security Number(s)/or Colorado account number of transferor: <br /> 4. Federal employer identification number of transferor: <br /> � 5/ - as- -7 0 -3J�- 0 <br /> 5. Type of property sold COMMERCIAL <br /> 6. Address or legal description of property 8133 COUNTY ROAD 28,PLATTEVILLE, <br /> CO 80651, <br /> 7. Date of Closin".e. 2X 2 2?z <br /> 8. Selling price of property $f D 3. 686 ,, o <br /> 9. Selling Price of this transferor's interest !0 3 G P Y <br /> 10. If Colorado tax was withheld,check here: <br /> 11. Amount of tax withheld$ <br /> 12. If withholding is not made,give reason(check one) <br /> a. Affirmation of Colorado residency signed 6t <br /> b. Affirmation of permanent place of business <br /> c. Affirmation of principal residence signed <br /> d. Affirmation of partnership signed <br /> e. Affirmation no tax reasonable estimated to be due <br /> Or no gain on sale signed <br /> f. No net proceeds <br /> 13. Name,address and telephone number of title insurance company or other person <br /> providing closing and settlement services with respect to this transfer: <br /> Lawyers Title Insurance Company <br /> 1099 18s'Street,Suite 2850 <br /> Denver,Colorado 80202 <br /> Case No.DLC 10467014 <br /> File this form together with form 1079,if applicable,within 30 days of the closing date with the <br /> Page 47 of 126 <br />