State Of Colorado Substitute Form W-9 - Request For Taxpayer Identification Number (Tin) Verification - 1997

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State of Colorado

Substitute Form

REQUEST FOR TAXPAYER IDENTIFICATION

W-9

Do NOT send to IRS

NUMBER (TIN) VERIFICATION

PRINT OR TYPE

RETURN TO ADDRESS BELOW

Legal Name

(OWNER OF THE EIN OR SSN AS NAME APPEARS ON IRS OR SOCIAL SECURITY ADMINISTRATION RECORDS)

DO NOT ENTER THE BUSINESS NAME OF A SOLE PROPIETORSHIP ON THIS LINE - See Reverse for Important Information

Trade Name -- complete only if doing business as (D/B/A)

Remit Address

Purchase Order Address -- Optional

PART II

See Part II Instructions on Back of Form

Check legal entity type and enter 9 digit Taxpayer Identification Number (TIN) below:

Do Not enter an SSN or EIN that was not

assigned to the legal name entered above

(SSN = Social Security Number

EIN = Employer Identification Number)

Individual

(Individual's SSN)

__ __ __ -- __ __ -- __ __ __ __

NOTE: If no name is circled on a Joint Account when there is more that one name, the number will be considered to be that of the first name listed.

Sole Proprietorship (Owner's SSN or Business EIN)

SSN

__ __ __ -- __ __ -- __ __ __ __

Note: Enter both the owner's SSN and the business EIN (if you are required to have one)

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

title. List and circle the name of the legal trust, estate, or pension trust.

Other >

(Entity's EIN)

___ __ -- __ __ __ __ __ __ ___

Limited Liability Company, Joint Venture, Club, etc.

Corporation

Do you provide medical services?

Yes

(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

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

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

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

(2)

(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 or abandonment of secure property,

contribution to an individual retirement arrangement (IRA), and payment 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 of under reporting interest or dividends on your tax return. (See Signing the Certification on the reverse of this form.)

THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT

OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING.

NAME (Print or Type) _______________________________________________

TITLE (Print or Type) _______________________________________

AUTHORIZED SIGNATURE _________________________________________

DATE _______________ PHONE (_______)_____________________

DO NOT WRITE BELOW THIS LINE

RETURN BOTH COPIES TO ADDRESS ABOVE

AGENCY USE ONLY

Agency ____ ____ ____

Approved by _________________________________