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:UI'Y <br />~~ ~ ~' CSSS~1~ 402 Main <br />Delta, CO 81416 <br />OWNERSHIP OF ACCOUNT -CONSUMER (Select One and Inhiel): <br />^ Single-Pally Account _ ^ TrustSeparate Agreement <br />^ MultlplaParty Arxount <br />^ Other <br />RIGHTS AT, DEATH (Select One and Initial): <br />^ Single-Party Account <br />^ Multiple-Party Aarount With Right of SuMvorehip <br />^ Multiple-Party Account Without Right of Survivorship <br />^ Single-Parry Axount With Pay On Death <br />^ Multiple-Partv Account With Right of Survivorship <br />and Pay On cam <br />PAY-0N-0EATH BENEFlCIMIES: To Adtl Pey-0n-Death aeneM1Cbries Name One w More: <br />OWNERSHIP OF ACCOUNT -BUSINESS PURPOSE <br />^ SOLE PROPRIETORSHIP .^ PARTNERSHIP <br />^ CORPORATION: ^ FOR PROFR ^ NOT FOR PROFlT <br />® PDPA 010004005101 <br />BUSINESS: <br />OFOORGANIZATION: <br />AUTHORIZ4TION DATED: <br />DATE OPENED 02~18/O3 SY 812 Ashmore <br />INITIAL DEPOSIT $ 5.667.00 <br />^ CASH ®CHECK ^ <br />HOME TELEPHONEx 874-9880 <br />BUSINESS PHONE # <br />DRIVER'S LICENSE x ' <br />E-MAIL <br />EMPLOYER <br />MOTHER'S MAIDEN NAME <br />Name antl adtlress of someone who will always know your location: <br />BACKUP WITHHOLDING CERTIFICATIONS <br />TIN: 523-50-7097 <br />TAXPAYER I.D. NUMBER -The Taxpayer Identification Number <br />shown above (TIN) is my correct taxpayer identification number. <br />BACKUP WITHHOLDING - I am not subject to backup withholding <br />either because I have not been notified that I am subject to backup <br />withholding as a result of a failure to report all interest or dividends, or the <br />Internal Revenue Service has notified me that I am no longer subjert to <br />backup withholding. <br />^ EXEMPT RECIPIENTS - I am an exempt recipient under the <br />Internal Revenue Service Regulations. <br />SIGNATURE: 1 certify under enalUas of perjury the statements <br />checked In this section nd t at 1 am a U.S. person (Inclutling a <br />U.S. slden all <br />X y O <br />(Date) <br />Eac~r~ii° ®1992 Bankers Systems, Inc., SL CbuE. MN Form CFB-MPSC-CO 1/19/2001 <br />ACCOUNT ` <br />NUMBER 4285071778 <br />ACCOUNT OWNER(S) NAME 8 ADDRESS <br />Western Slope Construction Co. <br />Assigned to: State of Colorado/lII.RB <br />1313 Sherman St., Room 215 <br />Deer, CO 80203 <br />®NEW ^ EXISTING <br />TYPE OF ^CHECKING ^SAVINGS <br />ACCOUNT ^ MONEY MARKET ®CERTIFICATE OF DEPOSIT <br />^NOw ® regular certif <br />This is your (check one): <br />FACSIMILE SIGNATURE(S)ALLOWED7 ^YES ~NO <br />X <br />SIGNATURE(S) - TM undersigned agree to Me terms stated on pages 1 <br />end 2 0} this form and acknowledge receipt of a completed copy. The <br />undersigned further authorize the flnanelal Inatitutlon to verity credit <br />and employment history and/or have a credit reportlng agency prepare <br />a credit report on the undersigned, as Intlivitluale. The underolgned <br />also acknowledge the receipt of a copy antl agree to the terms. of the <br />following dlaclosure(e): <br />® Deposh Account ^ Funds Availability ~ Pdvacy <br />^ Electronic Funds Transfer ®Truth in Savings <br />LL RO W. CATTAPY, Director <br />I.D. x Division of ?Iineralg Band Geology <br />l2k [x <br />I.D. # D.O.B. <br />(3) ~X <br />I.D. # D.O.B. <br />(4): [X <br />I.D. # <br />D.O.B. <br />AGENCY (POWER OF ATTORNEY) DESIGNATION (Optional): To Add <br />Agency Designation To Account, Name One or More Agents: <br />(Select One and Initial): <br />^ Agency Designation Survives Disability or Incapacity of Partias~ <br />^ Agency Designation Terminates on Disability or Incapacity of Ponies <br />(page t of 2) <br />