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988607 05/14/2023 01:21:56 PM Page 2 of 4 <br /> Jacklyn K. Harmon, Garfield County, Colorado <br /> Rec Fee: $28.00 Doc Fee: $0.00 eRecorded <br /> Street address <br /> --_ _(Street number and named — <br /> (City) --- (Store) (?dF#M d Code) <br /> (Province-#applicable) - — (country) <br /> Mailing address <br /> (leave blank if same as street address) (Street number and name or Post Office Box information) <br /> (City) (State) (ZIP/Posh!Code) <br /> (Provbrce-((a/pltartblt) rcaunrry) <br /> ID Number <br /> (Colorado Secretary of State ID number) <br /> Entity name or true name <br /> Form of entity <br /> Jurisdiction <br /> Street address <br /> (Sheet number and name) <br /> - (COY) - (Store) (ZIP/Pasial Code) <br /> (Province-ifappliaable) (C—try) <br /> Mailing address <br /> (leave blank if same as street address) (Street number and name or Past Office Box utOrmation) <br /> (Cory) (State) (Z/P/PwtoI Code) <br /> (Province-!(applicable) (Coanhy) <br /> (lfthe following statement applies,adopt the statement by marling the box and include an attachment.) <br /> ❑ There are more than three merging entities and the ID number(if applicable),entity name or true <br /> name,form of entity,jurisdiction under the law of which it is formed,and the principal address of <br /> each additional merging entity is stated in an attachment. <br /> 2. For the surviving entity,its entity ID number(if applicable),entity name or true name,form of entity, <br /> jurisdiction under the law of which it is formed,and principal address are <br /> 1D Number 20051069213 <br /> (Colorado Secretary of State ID member) <br /> Entity name or true name Ceerus PIceanc:e LLC <br /> MERGE DOM Page 2 oN Rev.U2912007 <br />