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12. (Optional) :Delayed effective date: <br />(mm/dd/yyyy) <br />13. Additional information may be included pursuant to other organic statutes such as title 12, C.R.S. If <br />applicable, mark this box ? and include an attachment stating the additional information. <br />Notice: <br />Causing this document to be delivered to the secretary of state for filing shall constitute the affirmation or <br />acknowledgment of each individual causing such delivery, under penalties of perjury, that the document is the <br />individual's act and deed, or that the individual in good faith believes the document is the act and deed of the <br />person on whose behalf the individual is causing the document to be delivered for filing, taken in conformity <br />with the requirements of part 3 of article 90 of title 7, C.R.S., the constituent documents, and the organic <br />statutes, and that the individual in good faith believes the facts stated in the document are true and the <br />document complies with the requirements of that Part, the constituent documents, and the organic statutes. <br />This perjury notice applies to each individual who causes this document to be delivered to the secretary of <br />state, whether or not such individual is named in the document as one who has caused it to be delivered. <br />14. Name(s) and address(es) of the <br />individual(s) causing the document COnradO Ellen Michelle <br />to be delivered for filing: <br />(Gast) (First) (Middle) (suffix) <br />592 Main (Street, Suite 2 <br />PO BOX 2aae name and number or Post Office Box information) <br />Meeker <br />(City) <br />A CO 81641 <br />U& States (P°stallipCode) <br />(Province - if applicable) (Country - if not US) <br />(The document need not state the true name and address of more than one individual. However, if you wish to state the name and address <br />ofany additional individuals causing the document to be delivered forfiling, mark this box F] and include an attachment stating the <br />name and address ofsuch individuals.) <br />Disclaimer: <br />This form, and any related instructions, are not intended to provide legal, business or tax advice, and are <br />offered as a public service without representation or warranty. While this form is believed to satisfy minimum <br />legal requirements as of its revision date, compliance with applicable law, as the same may be amended from <br />time to time, remains the responsibility of the user of this form. Questions should be addressed to the user's <br />attorney. <br />ARTORG-LLC <br />Page 3 of 3 <br />Rev. 11/16/2005 <br />