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., <br />n~VLLI V LLi <br />THE FIRST SECURITY BANK <br />190 P'1F1IN STREET <br />AKRON, ~ 80720 <br />(970) 345-2273 Qivision of Minerals 8 Geology <br />OWNERSHIP OF ACCOUNT -CONSUMER (Select One and Initial): <br />^ Single-Party Account ^ Trust-Separate Agreement <br />^ Multiple-Party Account <br />n Char <br />RIGHTS AT DEATH (Select One And Inidall: <br />^ Single-Party Account <br />^ Multiple-Party Account With flight of Survivorship <br />^ Multiple-Party Account Without Right of Survivorship <br />^ Single-Party Account With Pay On peath <br />^ Multiple-Party Account Wnh'fligh[ of Survivorship <br />and Pay On Death <br />PAY-0N-DEATH 6ENEFIC1AelE9: To Atltl Pey-0n-0eatb eenefidaries Name One or More: <br />OWNERSHIP OF ACCOUNT -BUSINESS PURPOSE <br />^ SOLE PROPflIETORSHIP ^ PARTNERSHIP <br />^ CORPORATION: ^ FOR PROFIT ^ NOT FOR PROFIT <br />~: DCtf1E!St1C GOVt Urilt <br />BUSINESS: STATE OF WIARADO <br />COUNTY & STATE - <br />OF ORGANIZATION: <br />AUTHORIZATION DATED: <br />DATE OPENED OC.'t. • 2O, 199'7 ev BETTY PECK <br />INITIAL DEPOSIT 5 5 • QQQ • I)Q <br />^ CASH SXCHECK ^ <br />e[75R1ESS PHONE g <br />DRIVffl'S LICENSE R <br />EMPLOYER <br />MOTHEfl'S MAIDEN NAME <br />Name and address of someone who will always know your location: _ <br />BACKUP WITHHOLDING CERTIFICATIONS <br />TIN: 84-0804085 <br />TAXPAYER I.D. NUMBER -The Taxpayer Identification Number <br />shown above iTINI is my correct taxpayer identification number. <br />BACKUP WITHHOLDING - I am not subject to backup <br />withholding either because I have not been notified that I am <br />subject to backup withholding as a result of a failure to report all <br />interest or dividends, or the internal Revenue Service has notified <br />me that I am no longer subject to backup withholding. <br />^ EXEMPT RECIPIENTS - 1 am an~exempt recipient under-the <br />Internal Revenue Service Regulations. <br />^ NONRESIDENT ALIENS • I am not a United States person, or <br />if I am an individual, I am neither a citizen nor a resident of the <br />United States. <br />SIGNATURE: I certify under penalties of perjury the statements <br />checked in this section. <br />X <br />IDatel <br />®1992 Bankers 9ystans. Inc., st, douq MN I1-800-39]-236D Farm MPBCiAZ-CO 5/eAB, <br /> <br />ACCOUNT 6600001573 <br />NUMBER' , . <br />AKRON READY IYIIX <br />ASSIQVID 'IO THE STATE OF OJUJRAllO <br />MINID LADID RECZANF~TION BOARD <br />PDPA #010004005101 <br />1313 SFTERM9N STREEP RIyI 215 <br />DEivvr~, cb so2o3 RELEASED <br />Division of <br />.Minerals & Geolnpv <br />~XNEW ~ ^ EXISTING <br />TYPE OF ^ CHECKING p^p SAVINGS <br />ACCOUNT ^ MONEY MARKET 1]A CERTIFICATE OF DEPOSIT <br />^ NOW ~g t~ ^ <br />This is your (check one/: Cottit~ 17- Nbnths t~ <br />rca.a <br />Permanent ^ Temporary account agreement. <br />Number of signatures required far withdrawal <br />FACSIMILE SI T (SI ALLOWE07 ^ YES ~NO <br />X <br />i4iCHAEI, B LONG. DIRF(:TOR <br />SIGNATURE(S) -THE UNDERSIGNED AGREE(SI TO THE TERMS <br />STATED ON PAGES 1 AND 2 OF THIS FORM,. AND <br />ACKNOWLEDGEf5) RECEIPT OF A COMPLETED COPY ON TODAY'S <br />DATE. THE UNDERSIGNED ALSO ACKNOWLEDGE(SI RECEIPT OF A <br />COPY OF AND AGREEfSI TO THE TERMS OF THE FOLLOWING <br />DISCLOSURE(Sl: <br />^ Deposit Account Disclosure ^ Funds Availability Disclosure <br />^ Electronic Funds Transfer Disclosure ^ TIS Disclosure <br />111: <br />I.D. M D.O.B. 1 <br />121: [X 1 <br />I.D. a <br />131: [X <br />D.O.B. <br />I.D. k ~ 0.0.6. <br />141: ~X <br />I.D. # <br />D.0.6. <br />AGENCY (POWER OF ATTORNEY} DESIGNATION IOpiionaq: To Add <br />Agency Designation To Account, Name One or More Agents: <br />(Select One and Initial/: <br />^ Agency Designation 9urvivea Duabili[y or Incapacity of Partiea <br />^ Agency Dazignatian Terminates on Disability or Incapacity of Parties <br />/page 1 0/ Z) <br />