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:. <br />x <br />0 <br />u <br /> <br />8 <br />9UTOMATIC ~ ~ • ~ e <br />RENEWABLE <br />!F• <br />first National Bonk <br />fIOGE NC E. COI bR~00 1~]1e <br />CERTIFIES nEPoSITFD .iUM O£ TRti~/{~LCRS r,...~ ,1....I rillll) inlpl ,~. ;i ~ ,, •illgl JIlryl <br />J n .... <br />- 218'1 -1::~~ L.~G ~Iwd ~p/ni .L.I';.: ;....I ~nlip ,nu,I ~. !.a <br />CERTIFICAiEp ND• 3712 <br />TERM NINE MONTHS <br />DOLLARS <br />PAYABLE TO C1'JSTER COUNTY CONCRETE JASSIGNED TO COLORADO LAND RECLAMATION DIVISION <br />ADDRESS P'0. BOX 305, WESTCLIFFE, CO. 81252 <br />SDC. SEC OR TAX ID. ND INTEREST RATE INTEREST PpYAOLE DATE OF ISSUE MATURITY DATE AMOUNT DEPOSITED <br />84-1148414 5.560 %a~~~mr QUARTERLY 9-23-91 6-23-92 8,800.00 <br />Payable at the undersigned's banking office, tb said Depositor, pr, if more than one, fo either orany b/sold Depositors or the survivors or survivor, upon presentation <br />and surrender of this certilicare, properly endorsed, an a maturity date, , <br />AUTOMATIC RENEWAL: This certificate matures on maturity date stated above, but will automatically be renewed tar successive terms, each epual to the <br />original term, unless and until one of the following contlitions occurs: 1) this certificate is personally presented for payment on a maturity date or within <br />ten tlays thereafter. 2) this bank receives written notice from a depositor before a ma[urlry tlate of the depositors inlentior, to redeem this cenifcate; 3) <br />not less than 7 days before a maturity date this bank mails to depositor written notice of its intention to redeem this certificate on a maturity tlate. <br />PAYMENT REQUESTED: <br />^ DEPOSIT INTEREST i0 ACCOUNT ND. ^ MAIL INTEREST LNECK ~ J <br />XS ADD INTEREST TD PRINCIPAL <br />(AUTHORIZED SIGNATURE) <br />NOTICE: TERM ANp CDNDITIDNS ON REVERSE 51 <br /> TYPE OF ACCOUNTS <br />PERSONAL BUSINESS <br />^ Individual >EtPartnership O Corporation <br />^ Joint -With Survivcnship ^ <br />^ Trust Account ^ Authorization Dated <br />^ Subject to Separate Agreement Dated ^ Numbec_of Signatures required for withdrawal or other purpose. <br />^ S b' t t T h' f f' ONN;~; <br />u lec o erms on t Is orm. Bene laanes named below. <br />^ Payable-On-Death. Beneficiaries named below. <br />I havl~e~r'era~d~an~d un~/~d~e_rsl~t~i+pn_ds[,FI~\~\+terms and conditions. <br />X - V V~ <br />Name & Address of Beneficiaries of Trust or PayOn-Death Accounts <br />NOTICE: Social Security or Employer's I.D. Number: "Under <br />Penalty of Perjury" I certify that the Soc. Sec. Number shown <br />above is my correct Taxpayer Identification Number. <br />UNDER PENALTIES OF PERJURY I CERTIFY THAT) A NOT <br />SUBJECT to backup withholding as a result of a failure to report <br />all interest or dividends, or the Internal Revenue Service has <br />notified me that I am no longer subject to backup withholding. <br />En~i~l ~s a~~g~~ r~~r~wii~a~o: <br />X Mike an an er Set ®~~ <br />X lvis n o ° ~ancdt~eclO~ti°~ <br />Office of Mined Land Reclamation, St of CO ~ <br />