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ESTERN FINANCIAL SUPPLIERtS, INC. (303) 487-9806 <br />-- - --- - - - -- - -- -- - <br />CT/tt174 T7x7AT <br />Type Account 13 Checking ? Savings IX CD PHONE <br />? Individual ? Joint ? Payable ? Revocable <br />?&usiness on Death Trust <br />ADDRESS RM 2155 Deaver, Co 80203 HOW LONG <br />I- -Man <br />me 5 AD HOW LONG <br />EMPLOYER HOW LONG t <br />PREVIOUS EMPLOYER HOW LONG <br />PREVIOUS BANK OTHER F.N.B. ACCOUNTS t <br />OPENED BY <br />LM <br />'WhNTIFICATION SUB PRODUCT DATE <br />i <br />Ay TAX CERTIFICATION I <br />Ay signing. I certify under penalty of perjury that the number shown on this form is my correct taxpayer identification <br />number, and that I <br />C3 am subject to backup withholding <br />g am not subject to backup whhhoiding either because (1) 1 have not been notifed that I am subject to backup E <br />withholding as a result o( a failure to reportall interest or dividends, or (2) the Internal Revenue Service has rwtified me f <br />that I am no longer subject to backup withholding. f <br />13 NonResident Aliens: By signing above. I certify under penalty of perjury that I am exempt from backup withholding and <br />information reporting as a non-resident alien, or as a foreign estate or trust, as described in the instructions provided. My <br />permanent resident address is <br />If this is a joint account, rune of the account holders is a U.S. citizen, resident, estate or bust. <br />By Ong Oft Signature Card, each of you agree to all the terns printed on the reverse side. You acknowledge having <br />' <br />received a copy of the Rul r rrst N I Bank Deposit Accounts and the Account Disclosure Brochure. <br />r <br />Sgnatu Date ?? <br />? CHEXSYSTEMS NS-71 <br />r•kiLWl`r7'T71LC ??????++++ %.va%rvtui11tjM AS5 <br />iTATE OF CO/ MINED LAND TOACCOUNTNUMBER <br />RECLAMATIO BOA ?D <br />AUTHORIZED SIGNATURE(S) SOC SEC / TAX ID N <br />Signature No. 1 <br /> PDPA # <br /> 010004005101 <br />Sip lure No. 2 <br />Signature No. 3 <br />Signature No. 4