PERMIT FILE - 3/17/2009, 12:44:39 PM-JWD

• Permit No: P2009002
• IBM Index Class Name: PERMIT FILE
• Doc Date: 3/11/2009
• Doc Name: Receipt of NOI
• From: DRMS
• To: Golden Age No. Two Mining Company
• Email Name: ACS
• Media Type: D
• Archive: No

Form W-9 I Request for Taxpayer

Substitute Form
Identification Number and Certification Give form to the
requester. Do not
State of Colorado 9-2007 send to the IRS.
Name
ri
a?
Business name, if different from above
a
c
0
a c Check appropriate box:
P,2 E3Individual/ Sole Proprietor ? Corporation Partnership ? Other [3Exempt from backup withholding
O .« ? .....................
c Address (number, street, and apt. or suite no.) Requester:
(L 0
CL City, state, and ZIP code.
U)
d
N List Account number(s) here (optional) Phone Number:
Tax a er Identification Number TI

Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN) However,
for a resident alien
sole proprietor
see the Part I instructions on
or disregarded entity
a
e 3
For Social Security number
,
,
,
p
g
.
other entities, it is your employer identification number (EIN). If you do not have a number, see How to get
a TIN on page 3.
Note: If the account is in more than one name, see the chart on page 3 for guidelines on whose Employer identification number
number to enter
. I I FT - TT L L
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. 1 am not subject to backup withholding because. (a) I am exempt from backup withholding, or (b) I have not been notified by the
Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or
(c) the IRS has notified me that I am no longer subject to backup withholding, and
3. 1 am a U.S. person (including a U.S. resident alien).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN. (See the instructions on page 3.)
Sign Signature of
Here U.S. person ? Date ?
Minority and Women-owned Businesses (MIWBEs) Self Certification (Please check all boxes that apply)
In an effort to track levels of participation by women and minorities doing business with the State of Colorado, the following information is
requested. Please indicate the appropriate category of ownership for your company. "Owned" in this context means a business that is at least 51
percent owned by an individual(s) who also control(s) and operate(s) it. "Control" in this context means exercising the power to make policy
decisions. "Operate" means actively involved in the day-to-day management. If you business is jointly owned by both men and women or is a
large publicly held corporation, please check the box labeled "Not Applicable."
Gender Information:
? Female-Owned ? Male-Owned
Owner Ethnicity Information
? African American ? Asian/Pacific American
? Hispanic American ? Native American
Small Business information
? Not Applicable
? White (non-Hispanic)
? Other:
? Not Applicable
Small Business (a business that is organized for profit, is independently owned and operated, and has 25 or fewer full time equivalent
employees.)
? Yes ? No