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OR <br /> (if an entity) <br /> (Caution: Do not provide both an individual and an entity name.) <br /> Street address <br /> (Street number and name) <br /> CO <br /> (Cly) (State) (ZIP Code) " <br /> Mailing address <br /> (leave blank,if same as street address) (Street number and name or Post Office Box information) <br /> CO <br /> (Ciy) - (State) (ZIP Code) <br /> 6. (If applicsible,adopt the following statement by marking the bar and include an attachment.) <br /> 0 This document contains additional information as provided by law. <br /> 7.(Caution:.Leave blank•ifthe document does not have a delayed effective dale. Stating a delayed effective date has significant <br /> legal consequences. Read instructions before entering a date.) <br /> (If the following statement applies,adopt the statemenuby entering a date and if applicable:time;usin the requiredformat.) <br /> The delayed effective date and,if applicable,.time of this doc'umerit:are. 04/01/2017; 12:01 a.m. <br /> (mm/dd/yyyy hour:minute am/pm) <br /> Notice: <br /> Causing this document to be delivered to the Secretary of State for filing shall constitute the affirmation or <br /> acknowledgment of each individual causing such delivery,under penalties of perjury,that such document is <br /> such individual's act and deed,or that such individual in good faith believes such document is the act and deed <br /> of the person on whose behalf such individual is causing such document to be delivered for filing,taken in <br /> conformity with the requirements of part 3 of article 90 of title 7,C.R.S.and, if applicable,the constituent <br /> documents and the organic statutes,and that such individual in good faith believes the facts stated in such <br /> document are true and such document complies with the requirements of that Part,the constituent documents, <br /> and the organic statutes. <br /> This perjury notice applies to each individual who causes this document to be delivered to the Secretary of <br /> State,whether or not such individual is identified in this document as one who has caused it to be delivered. <br /> 8. The true name and mailing address of the individual causing this document to be delivered for filing are <br /> Hahne Clifford ' • <br /> (last) (First) (Middle) (Suffer) • <br /> 301 Centennial Drive <br /> (Street number and name or Post Office Box Information) <br /> • <br /> Milliken CO 80543 <br /> • <br /> (City) USA <br /> $(State) (ZIP/Postal Code) <br /> (Province-rf applicable) A(Country) <br /> (If applicable,.adopt the following statement by marking the box and include an attachment.) <br /> 0 This document contains the true natio and mailing address of one or more additional individuals <br /> causing the document to be delivered for filing. <br /> MERGE FGN Page 4 Rev.5/29/2007 <br />