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111111111111111111 III 111111111111111111 III 111111111 IN <br />3767632 05/1012011 11:27A Weld County, CO <br />2 of 2 R 16.00 0 0,00 Steve Moreno Clerk & Recorder <br />7. Name(s) and address(es) of the <br />individual(s) causing the document <br />to be delivered for tiling: Seedig Sarah Niemiec <br />(lase) (Frst) (Afiddle) (Sufi) <br />1200 17th Street <br />Suite 24061"ei "0111'"d ),umborm Post Offce Box it jortn0riort) <br />Denver CO 80202 <br />(city') Unfted)States (Posralfape'de) <br />(Province -if'pp/imLk) ? (C'ur'ry-lfn'r14) <br />(The doctment nerd not state the rive name acrd address of nrore than ore iodicid+ml. (ltrn'ever, {?)ron wish ro mate i1+C +ranx and addrl5a <br />of am)•addittonal tndividwis carrithg rho document to be dchwed far filing, mark dds b'r Q umd inc/trde tar arraN?menr crating the <br />Warne and crddress'Jnrch nulividrmis.J <br />Disclaimer: <br />'Mis form, and any related instructions, are not intended to provide legal, Wsiness 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 ofthis form. Questions should be addressed to the user's <br />attorney. <br />AMD = Page 2 of 2 Rev. %1 /2D I O