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V MLLS Time Account Change Request <br />]'ARGO <br />Please retain this document with the on/ginal certificate when applicable qICZ0,01 <br />Section 1: Customer and Account /reformation .(I^_ <br />'tame Account tweimamng Huuress <br />ANTHONY J KIMMICK ANTHONY J KIMMICK rs70rjo y ° <br />Taxpayer identification number (TIN) Account number STATE OF COLORADO r.,- `.l <br /> <br /> number r rq ?pG,BO, <br />-? 1 DIVISION OF MINERALS AND GEOLOGY <br />AM toq DENVER CO 80203 2243 <br />Section 2: Amended Terms Reri' final': I omplete Section 6 when funds are withdrawn) (Time Accounts/Retirement Accounts only) <br />New term Mat ( New interest rate Negotiable rate <br />t <br />Section 3: Payment Method/Frequency Change (Time Accounts/Savings Certificates only) <br />Interest payment method (TO 11) Effective date <br />? Credit Principal (TA) ? Check (CO) ? Credit Checking (TT) ? Credit Savings (TT) <br />? Checking <br />? Savings <br />? Internal (Zero fill or blank) <br />? External <br />Interest payment cycle <br />? Monthly (IM) ? Quarterly (IQ) ? Semi-Annual (IS) ? Annual (1Y) ' ? At end of term if term = 12 months or less (00) <br />Section 4: Trade-A-Rate Option - - Section 5: Re-Open Account <br /> Date closed in error Dollars available for W/D without penalty Maturity date <br />Add Trade-A-Rate option ? <br />Effective date Interest Rate <br />Section 6: Disbursement/Payment Receipt (Time Account/Savings Certificates only) <br />Amount Withdrawn Penalty Amount <br />5,420.99 <br />Funds disbursed to me by: 5H(5 <br />?X A new time account 5,420.99 <br />? An official check Number $ <br />? Credit to account Number $ <br />Section 7: Customer Signature <br /> <br />I authorize the Bank to make the above changes to my time account. The Bank will automatically renew my time account at maturity <br />unless I notify the Bank otherwise. If h6?"'":hange includes a new term, I acknowledge receipt of and agree to the applicable account <br />agreement and the applicable fee_p).O ormation schedule. <br />Customer signature Data <br />X / <br />Customer signature Date <br />X <br />Section 8: Banker Information <br />Banker name Banker phone number Approval Officer number Office number <br /> 1059 <br />SARAH SULLIVAN 303 933-5370 K_ 1630 <br />? Send check to address other than account address <br />W 70AI89 /5-99-3462-?) Pll