1995-06-21_GENERAL DOCUMENTS - C1981017

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Substitute Form REQUEST FOR TAXPAYER IDENTIFICATION Colorado Department of Administration W-9 NUMBER(TIN)VERIFICATION Do NOT send to IRS PRINT OR TYPE RETURN TO ADDRESS BELOW Legal Name &a.ry ��K�� N r'e �� Ks� .T� �• DO NOT F THE BUSINESS NAME OF A SOLE PROPRIErORSHIP ON THIS LINE-See Reverse for Important Information Trade Name STATE OF COLORADO DIVISION OF MINERALS & GEOLOGY COMPLETE ONLY IF DOING BUSINESS AS(DB/A) 1313 SHERMAN STREET, RM 215 Mailing Address S y z- 3 3 DENVER, CO 80203 City,State,Zip, L°1.4 f va1 L°o 1� �lSz O Remit Address-Optional Atto: Deborah Mu 11 oy City,State,Zip, Order Address -Optional City,State,Zip, Check legal entity type and enter 9 digit Taxpayer Identification Number(TIN)below: 1 r r r r (SSN=Social Security Number EIN=Employer Identification Number) r r r r ❑ Individual (Individual's SSN) NOTE:If no name is circled on a Joint Account when there is more than one name,the number will be considered to be that of the first name listed. --- -- ---- ❑ Sole Proprietorship(Owner's SSN or Business FEIN) SSN NOTE:Enter both the owners SSN and the business EIN(if you are required to have om) EIN ❑ Partnership ❑General ❑Limited (Partnership's EIN) ❑ Estate/Trust (Legal Entity's EIN) NOTE:Do not furnish the identification number of the personal representative or trustee unless the legal entity itself is not designated in the account tide.List and circle the narne of the legal must estate.or pension true -- ------- ❑ Other Groups of Individuals (Entity's EIN) _ (Limited Liability Company,Joint Venture.Association.Club) Corporation Do you provide medical services? ❑Yes EZNo (Corp.'s EIN) (Includes corporations providing medical billing services) ❑ Government(or Government Operated)Entity (Entity's EIN) ❑ Organization Exempt from Tax under Section 501(a) (Org's EIN) Do you provide medical services? ❑Yes ❑No —— ——————— ❑ Check Here if you do not have a SSN or EIN,but have applied for one.See reverse for information on How to Obtain A TIN. Licensed Real Estate Broker? ❑Yes ❑No Under Penalties of perjury,I certify that: (1) The number listed on this form is my correct Taxpayer Identification Number(or I am waiting for a number to be issued to me)AND (2) I 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(does not apply to real estate transactions,mortgage interest paid,the acquisition of abandonment of secured property,contribution to an individual retirement arrangement(IPA),and payments other than interest and dividends). 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 or under reporting interest or dividends on your tax return.(See Signing the Certification on the reverse of this form.) NAME(Print or Type) C—O-b^v In t N L TITLE(Print or Type) �ilrr¢s r U c h AUTHORIZED SIG NATU n DATE [-2 t S PHONE(33 ) q3 y-O5 DO NOT WRITE BELOW THIS LINE RETURN BOTH COPIES TO ADDRESS ABOVE AGENCY USE ONLY Agency — _ _ Approved By Date 1099 Y_ N_ VEND Addition— Change— Action Completed By Date 395-53-07-6066(R 10/94)