Laserfiche WebLink
1 •1 1 <br />PERSONAL <br />^ Individual <br />^ Joint -With Survivorship <br />^ Trust Account <br />^ Subject to Separate Agreement Dated <br />^ Subject to Terms on this form. Beneficiaries named below. <br />Payable-On-Death. Beneficiaries named below. _ <br />have read and understand the terms and conditions as set forth <br />m the r erse slde. <br />~7Xi%'~~ ~l ~i~1~i L;~ <br />Name & Address of Beneficiaries of Trust or Pay-On-Death <br />Accounts <br />TYPE OF ACCOUNTS NOTICE: TERM AND CONDITIONS ON REVERSE SIDE <br />BUSINESS DATE RATE <br />^ Partnership ^ Corporation <br />O Authorization Dated <br />^ Number of Signatures required for withdrawal or other purpose. <br />^ BACKUP WITHHOLDING -Under Penalties of Perjury I certify that I am not subject to Backup <br />Withholding, either because I have not been notified that I am subject to back withholding as <br />a result of a failure to report all interest or dividends, or the Internal Revenue Service has notified <br />me that I am no longer subject to backup withholding. <br />^ EXEM% RECIPIENTS -Under Penalties of Perjury I certify that I am an Exempt Recipient under <br />the law governed by Income Tax Regulations 31.3452(c), lib) through (~. <br />^ NONRESIDENT ALIENS -Under Penalties of Perjury I certify that I am not a citizen nor resident <br />of the United States. <br />^ NOTICE: Social Security or Employer's I.D. Number: "Under Penalty of Perjury" I cenify that [he <br />Soc. SEEr-jVumbersyownyelow isyy{ correct Taxpayer Identification Number. <br />MOUNTAIN NATIONAL RANK <br />Woodland Park, Colorado 80866 <br />CERTIFIES DEPOSITED SUM OF: $ 5 ~.~ <br />Term <br />Date <br />Date <br />No _5539 <br />FIVE l}i0t1~SMD APD f~/1.00-- ----- --- --- DOLLARS <br />PAYABLE TO Mined LEtrxJ Reclamation BDard far .Jack G (xfirrt ~ Stone Faroe <br />ADDRESS ~~ 9TeLnen St' RDaT 275, Del'IVaT, CA 211203 <br /> SOC. SEC.OR TA%ID.N INTEREST RATE INTEREST PAYABLE DATE OF ISSUE MATURITY DATE AMOUNT DEPoSITED <br />0 4.25 % aon mr Itgttthly 7/3/92 7/3/93 $ 5r000.0~ <br />Payable at the undersigned's banking of/ice, to said Depositor, or, i/more than one, to either orany of said Depositors or the survivors or survivor, upon presentation <br />~ and surrender of this certificate, properly endorsed, on a maturity dale. <br />Interest will be calculated on a basis of ^ 360 days A 365 days. Interest will be compounded S31iDIE 17TtaL2St <br />g ^ SINGLE MATURITY: Present this certificate promptly at maturity for payment as it is not automatically renewable and no interest will accrue after the maturity <br />f date shown. . <br />X3 AUTOMATIC RENEWAL: This certificate maWres on maturity date stated above, but will automatically be renewed for successive terms, each equal to the <br />original term, unless and until one of the following conditions occurs: 1) this certificate is personally presented far payment on a maturity date or within <br /> thereafter; 2) this bank receives written notice from a depositor before a maturity tlate of the depositor's intention to redeem this certificate; 3) <br />u not less than 7 days before a maturity date this bank mails to depositor written notice of its intention to retleem this certificate on a maturity date. <br />PAYMENT REQUESTED: ff~Afl~ ' <br />DEPOSIT INTEREST TOACCOUNT NO. ^MAIL INTEREST CHEGK ~~~- ~. <br />^ADD INTEREST TO PRINCIPAL (AUTHORIZED SIGNATURE} <br />