Laserfiche WebLink
ime Account Signature Card/W-9 <br />WELLS <br />FARGO <br />rrequesr ror I axpayer Identification Number and Certification (Substitute Form W-9) <br />Certification: Under penalties of perjury, I certify that: <br />1) The number shown on this form is my correct Taxpayer Identification Number, and <br />2) UNLESS I HAVE CHECKED ONE OF THE BOXES BELOW, I am not subject to backup withholding either because I have not been notified by the <br />internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the IRS has <br />notified me that I am no longer subject to backup withholding (does not apply to real estate transactions, mortgage interest paid, the ac uisition or <br />abandonment of secured property, contributions to an Individual Retirement Arrangement (IRA), and payments other than intere divides , and <br />3) I am a U. S. person (including a U. S. resident alien). <br />F] I am subject to backup withholding El I am exempt from backup withholding Signature. <br />X z <br />Depositor(s) name and address <br />DICK CASEY CONCRETE CO ASSIGNED TO STATE OF COLORADO/MINED LAND Account number <br />RECLAMATION BOARD PDPA 010004005101 <br />1313 SHERMAN ST STE 215 Taxpayer identification number <br />DENVER CO 80203-2243 84-19,28674 <br />? Temporary signature card <br />? Need certification <br />Signature: <br />I have received a copy of the Bank's Time Account ReceiptlDisclosure, applicable account agreement, and applicable fee and information schedule <br />and agree to be bound by them. <br />Signatu (s) <br />X X <br />Ronald W. Cattany, Director Division of Minerals and Geology <br />X X <br />Date ZQd3 <br />W 74W50 (6-01-45320-J) PII `t"