HomeMy WebLinkAbout951336.tiffRESOLUTION
RE: APPROVE CHANGE OF OWNERSHIP REQUEST FOR TAVERN LIQUOR LICENSE,
WITH EXTENDED HOURS, FROM DEL CAMINO, INC., DBA LAS CARRETAS DEL
CAMINO, TO ROBERT W. KLINE, DBA REWARDS BAR AND GRILL
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, Robert W. Kline, dba Rewards Bar and Grill, presented to the Board of County
Commissioners of Weld County, Colorado, an application for a Change of Ownership of a Tavern
Liquor License, with extended hours, for the sale of malt, vinous and spirituous liquors for
consumption by the drink on the premises only, said license previously held by Del Camino, Inc.,
dba Las Carretas Del Camino, and
WHEREAS, pursuant to Weld County Ordinance No. 6, Section II., C., said applicant has
paid the required fees to the County of Weld for a Change of Ownership of the existing license, and
WHEREAS, said applicant has exhibited a State Liquor License for the sale of malt, vinous
and spirituous liquors for consumption by the drink on the premises only, with extended hours,
outside the corporate limits of any town or city in the County of Weld at the location described as
follows:
10763 Turner Blvd., Longmont, Colorado 80504-9578
NOW, THEREFORE, BE IT RESOLVED that the Board of County Commissioners of Weld
County, Colorado, having examined said application and the other qualifications of the applicant,
does hereby grant License Number 95-11 to said applicant to sell malt, vinous and spirituous
liquors for consumption by the drink on the premises only, only at retail at said location and does
hereby authorize and direct the issuance of said license by the Chairman of the Board of County
Commissioners, attested to by the Clerk to the Board of Weld County, Colorado, which license shall
be in effect until June 21, 1996, providing that said place where the licensee is authorized to sell
malt, vinous, and spirituous liquors for consumption by the drink on the premises only, with
extended hours, shall be conducted in strict conformity to all of the laws of the State of Colorado
and the rules and regulations relating thereto, heretofore passed by the Board of County
Commissioners of Weld County, Colorado, and any violations thereof shall be cause for revocation
of the license.
951336
LC0042
C c: ke,c-a.ds) s�
CHANGE OWNERSHIP OF TAVERN LIQUOR LICENSE - REWARD'S BAR AND GRILL
PAGE 2
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 12th day of June, A.D., 1995.
ATTEST
Weld County Clerk to the Board
BY
Deputy'CAerk' the Board
tiiy—�
�)1--
APPRO D AS TO FQR
oun
4y Attey'
BOARD OF COUNTY COMMISSIONERS
WFLQCOUNTY, COLORADO
Dale K. Hall, Chairman
ditUt fAitAzizzi-'
arbarar -Til. Kirkmeyer, em
t_
f~�//-
e E.Baxter
to ce—e-4 i(/YG zze
Constance L. Harbert
W.H.p/kY
951336
LC0042
THIS LICENSE MUST BE POSTED IN PUBLIC VIEW
III
DR 84021101921
STATE
DEPARTMENT
ALCOHOLIC
OF COLORADO
OF REVENUE
Liquor Enforcement Division
1375 Sherman Street
Denver, Colorado 80261
KLINE ROBERT WILEY
REWARDS BAR & GRILL
10763 TURNER BLVD
LONGMONT CO 80504-9578
BEVERAGE LICENSE
Account Number
Liability Information I
'
AT MIDNIGHT
County City Indust. T I LICENSE EXPIRES
ype Liability Date,
23-39311-0000 03 206 5812 I 062295 I JUN 21, 1996
Type
Name and Description of License i Fee
1970
{
2190
HOTEL AND RESTAURANT � $ 50.00 I,
LIQUOR LICENSE - MALT,
VINOUS, AND SPIRITUOUS
COUNTY 85 PERCENT OAP FEE $ 276.25
EXTENDED HOURS TOTALFEEISi
This license is issued subject to the laws of the State of Colorado and especially
provision of Title 12, Articles 46 or 47, CRS 1973, as amended.
nontransferable and shall be conspicuously posted in the place above described.
only valid through the expiration date shown above. Questions concerning this
be addressed to the Department of Revenue, Liquor Enforcement Division,
Street, Denver. CO 80261.
�p testimony whereof, I have hereunto set my hand.
� l
JUN_231995 ��
Division Director Executive
$ 326.25
under the
This license is
This license is
license should
1375 Sherman
e
Director
951336
1/40
.r
THIS LICENSE EXPIRES
O
MALT, VINOUS,
TO SELL AT RETAIL
DBA REWARDS
ROBERT W. KLINE,
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951336
� r?qP L cc%r)�i'si itjJ
OH ti404 (l awcr)
COLORADO DEPARTMENT OF REVENUE
LIQUOR ENFORCEMENT DIVISION
1375 SHERMAN STREET
DENVER CC80261
OLORADO LIQUOR OR 3.2 % FERMENTED MALT BEVERAGE
LICENSE APPLICATION
1. Applicant is a
❑ Corporation (Attach DR 8177)
❑ Partnership (Attach DR 8441)
la. Nwne of Applicant(s) If partnership, list part e names (at least two); if corporation, name of corporation
2E�T G(//.4 AA,/e,
2. Trade Name of Establishme (D A ('�/
/*/4 --am eff . A
3. Address of Premises (specify exact location of premises �� C7,44-7 /N O
/0 7,4 3 72'R NEk ftl v0
County !vino
City j wA
» ,✓IOn/ .
4. Mailing Address (Number and Street)
J.A 4 E -
5. If the premises currently have a liquor or beer license, you MUST answer the following question:
PrebI TIYpyCi A Lic9nse
City or Town
abilityt officers,Yes thelimited company;ICJ
ers or directors if a corporation) or manager under the age of twenty-one years?
7 Has the applicant (including any of the partners, if a partnership; members or manager if a limited liability company; or officers, stockhold-
ers or directors if a corporation) or manager ever;
(a) been denied an alcoholic beverage license? ❑
(b) had an alcoholic beverage license suspended or revoked? ❑
(c) had interest in another entity that had an alcoholic beverage license suspended or revoked?
If you answered yes to 7a, b or c, explain in detail on a separate sheet.
8. Has a liquor license for the premises to be licensed been refused within the preceding two years? If "yes," explain in detail.
8a. Has a 3.2 beer license for the premises to be licensed been refused within the preceding one year? If "yes," explain in detail.
9 Are the premises to be licensed within 500 feet of any public or parochial school, or the principal campus of any college, university or
seminary?
10. limited ted liquor
abilityr beer company; or officers, stockholdse ever been issued ers or directors flaccorporation)? If yes, identify the name ofing any of the partners, if a lth business and list any a
current financial interest in said business including any loans to or from a licensee.
11. Does the Applicant, as listed on line 1a of this application, have legal possession of the premises for at least 1 year from the date that
this license will be issued by virtue of ownership or under a lease? (If yes, attach a signed copy of deed or lease.)
❑ Ownership Lease ❑ Other (Explain in Detail)
a. If leased, list name of landlord and tenant, and date of expiration, EXACTLY as they appear on the lease:
Tenant l obe!'"f. h✓' kllnP
Stto
State
Date fit with Loca9ufrity
F.E.I.N.
Sod Security No.
g1esse0ft/one0 //'
ZIP crof0
ZIP Code
Present State License No.
Present E iratio Date
643/7 76
Landlord o�-r 1l1Rd Isabel
f /7b(l� vnf-�If 1�mr //f•^
Attach a diagram of the area o be licensed (including dimensions) which shows the bars, walls, partitions, entrances, exits and what each
room shall be utilized for in this business. This diagram should be no larger than 8 1/2" X 11". (Doesn't have to be to scale)
12. Who has (including persons, firms, partnerships, corporations, limited liability companies) or will loan or give money, inventory, furniture or
equipment to or for use in this business; or who will receive money from this business. Attach a separate sheet if necessary.
INTEREST
❑ ICJ
YJ ❑
Expires
3/3/ /9t.
❑ �1
NAME
ADDRESS
Attach copies of all notes and security instruments, and any written agreement or details of any oral agreement, by which any person
(including partnerships, corporations, limited liability companies, etc) will share in the profit or gross s proceed ^o/had vice s establishment,
hment, arnd any
agreement relating to the business which is contingent or conditional in any way by volume, profit, giving
ion.
13. Optional Premises or Hotel and Restaurant Licenses with Optional Premises
All Optional Premises applicants must attach a copy of the local ordinance or resolution authorizing the issuance of Optional Premises
licenses.
Number of separate Optional Premises areas requested
951336
DR 8404 (2/94) Page 2
14. Liquor Licensed Drug Store applicants, answer the followin•
l
g
(a) Does the applicant for a Liquor Licensed Drug Store have a license issued by the Colorado Board of
Pharmacy? COPY MUST BE ATTACHED.
15.
.....
Yes No
•
Club Liquor License applicants answer the following and attach DR 8177:
(a) Is the applicant organization operated solely for a national, social, fraternal, patriotic, political or athletic purpose and
not for pecuniary gain?
(b) Is the applicant organization a regularly chartered branch, lodge or chapter of a national organization which is
operated solely for the object of a patriotic or fraternal organization or society, but not for pecuniary gain? (c) How long has the club been incorporated? (d) How long has applicant occupied the premises
(Three years required) to be licensed as a club?
❑ •
Li •
16. Colorado Manufacturer, Wholesaler or Limited Winery applicants, answer the following:
(a) Will the applicant store or sell alcoholic beverages at more than one location in Colorado? If "yes," provide the
address of each location and explain the activity to be conducted at each location (e.g., warehouse, salesroom, etc.)
(Attach DR 8438 for each location)
(b) If applicant is a wholesaler, does or did any owner, partner, shareholder, director, officer, member or manager have any
or indirect financial interest in a wholesaler, retailer, manufacturer or importer already licensed by the State of Colorado
malt, vinous or spirituous liquor? If yes, attach explanation in detail.
(c) Does the applicant have a valid Federal Basic Permit or Brewers Notice? If "yes," attach a copy; if "no; explain whether
one has been applied for.
❑ ■
direct
to sell
• ❑
••
17. Nonresident Manufacturer (3.2% beer or
the following:
(a) To what Colorado licensed wholesaler
(b) Does or did any owner, partner, shareholder,
interest in a wholesaler, retailer, manufacturer
spirituous liquor? If yes, attach explanation
(c) Does the applicant have a valid Federal
(d) Are you the primary source of supply
(e) Are all your products registered in Colorado?
18. Name
malt liquor) or Importer (3.2% beer, malt, vinous or spirituous liquor) applicants, answer
do you intend to ship your merchandise?
director, officer, member or manager have any direct or indirect financial
or importer already licensed by the State of Colorado to sell malt, vinous
in detail.
Basic Permit or Brewers Notice? If "yes," attach a copy; if "no," explain in detail.
in the U.S.? If "no," explain.
If "no," attach DR 8440 and register said products.
or
■ ❑
El
•.
❑
of Manager Of this is an application for a Hotel and Restaurant License, the manager must also submit a Manager Registration Form
pik
/ ` /
§7t) Indry I History Re ord (DR 840 - /�
Date of Birth
[''
OATH OF APPLICANT
I declare under penalty of perjury in the second degree that this application and all attachments are true, correct, and
complete to the best of my knowledge.
Author Signature
/L
W
Title
/C) ��EA
Date
ifREPORT
AND APPROVAL OF LOCAL LICENSING AUTHORITY
(Manufacturers, nonresident manufacturers, importers, wholesalers, limited wihedes. and jfub
ow.}
disregard the section belne
iOZF IIC!31isen
Is this application for a: ❑ New License
Each person required to file DR 8404-I:
Has been fingerprinted
Background, NCIC and CCIC checked
The liquor licensed premises is ready for occupancy
If "no," the building will be completed and ready
Ad Transfer of Ownership ■ Other (specify)
and has been inspected by the Local Licensing Authority.
for inspection by
Yes No
•
(date)
The foregoing application has been examined; and the premises, business to be conducted, and character of the applicant are satisfactory. We do
report that such license, if granted, will meet the reasonable requirem of the neighborhood and the desires of the inhabitants, and will comply
with the provisions of Title 12, Article 46 or 47, C.R.S. THER , IS APPLICATION IS APPROVED.
Local Licensing Authority for L,"'
WELD COUNTY, COLORADO
TOWN, CITY
COUNTY
IN
�
sig"�,e.�
„ 1 )
Tine CHAIRMAN, WELD COUNTY BOARD
OF COMMISSIONERS
Date
06/12/95
Signature(attest)
Tine WELD COUNNT�tERK TO THE BOARD
BY: A,FA Qom/ ,tier4i.,,. DEPUTY
Date
06/12/95
If premises are located within a town twit.,
c,
DR 8404-I (02/94)
COLORADO DEPARTMENT OF REVENUE
LIQUOR ENFORCEMENT DIVISION
1375 SHERMAN STREET
DENVER CO 80261
INDIVIDUAL HISTORY RECORD
To be completed by each individual applicant, all general partners of a partnership, all limited partners owning 10% (or more) of a
partnership; all officers and directors of a corporation, all stockholders of a corporation owning 10% (or more) of the stock of such
corporation; all limited liability company MANAGING members, or other limited liability company members with a 10% (or more)
ownership interest in such company and all managers of a Hotel and Restaurant license.
NOTICE: This individual history record provides basic information which is necessaryforthe licensing authorities investigation. ALL questions
must be answered in their entirety. EVERY answer you give will be checked for its truthfulness. A deliberate falsehood will jeopardize the
application as such falsehood within itself constitutes evidence regard ng the character of the applicant.
1. Name of usiness
r� AAV s &4X d G,ei//
DateSocial
-6- 9S
Security Number(s)
�/ �'
2. Y ur Full ame (last, first, addle)
� ( � n/ Jai O,MER7- %(//'( Ey
3. Also Known As (maiden name/nickname, etc.)
4. Mailing Address (if diffe nt rom residence) //
Home Telephone
302 y.1/- 6e 7 ff-s-
5. Residence Address (street and number, city,
865-8 6 AK t 4,4/.0
state, ZIP)
CT, " A 1(/,4i ( A CO • .,00.0_5-
6. Date of Birth
Place of Birth
,✓!4Af,//4 (:),{1A //a.444
7. U.S. Citizen?
Eyes No
If Naturalized, state where
When
Name of U.S. District Court
Naturalization Certificate Number
Date of Certificate
Ilan Alien, Give Alien's Registration Card Number
Permanent Residence Card Number
8. Height
Weight
aye
Hair Color
5*vxt'i
Eye Color
46ti vc
Sex
44 LG
Race
CA,C ;s,,,e
9. Do You Have a current Drivers License? If yes give number, & state
'Yes ❑ No ,>'
10. ame of PrW Employer I/ O
E fi S4 lei-
11. Types BusinessoreEmployment Z
54 if
12. Address of Business Where Employed (street number, city, state, ZIP)
6<2 99 FE-0rti( Eva. Dei VerCO 570 ao /
Business Telephone
263 5/.6- 94/6V
13. Present Position
O /,!/N F
14. Marital Status
A/RifFta
15. Name of pouse (include maiden name if applicable)
1(Lt i c/%L fr/t i
16. Spouse's Date of Birth
"/.
Spouse's P ace of Birth
44-,v(i,eg c0.4 a trio
17. pouse's residence address, if different than yours (street and number, city, state, ZIP)
18. Spouse's resent Emplo r
/�& fe l' 4A --Ay
Occupation
-. "A L � r
19. Address of Spouse's Present Employer
/oy// �,�+-�l� n, 14� i VA121 sx7%7 x l ,i? /„�/,/
20. List the name(s) of all relatives working in or having a financial interest in the liquor industry.
NAME OF RELATIVE
RELATIONSHIP TO YOU
POSITION HELD
NAME OF EMPLOYER
LOCATION OF EMPLOYER
21. Do you now, or have you
Licensee? If yes, answer
❑ Yes pi
ever held a State of Colorado Liquor or Beer License, or loaned money, furniture, fixtures, equipment or inventory, to any Colorado Liquor or Beer
in detail
No
95 1 336
CONTINUED ON REVERSE SIDE
Dh 8404-I (2/94) rage e
22. Have you ever been convicted of a crime, or received a suspended sentence, deferred sentence, or forfeited bail for any offense in criminal or military court? (Do not include traffic
violations, unless they resulted in suspension or revocation of your driver's license, or you were convicted of driving under the influence of drugs or alcoholic beverages.) If yes,
explain in detail.
H Yes iDe No
23. Have you ever received a violation notice, suspension or revocation for a liquor law violation, or been denied a liquor or beer license anywhere in the U.S.? If yes, explain in detail.
C Yes iW No
24. Military Service (branch)
_
eS �4vy
From
i-j
To
8- E?
Serial Number
X79- 79- c/57
Type �//of Discharge
��1 C_.
a
.1
/'mA
25. //
List all add esses where you have lived for the past five years. (Attach separate sheet if necessary)
STREET AND NUMBER
CITY, STATE, ZIP
FROM
TO
y5
& cl 11,14irn Cr-
ApU.4o4 ro, cS'-UC.Ci5
2., y'o
6 /S
26.
List all former employers or businesses engaged in within the last five years. (Attach separate sheet if necessary.)
NAME OF EMPLOYER
ADDRESS (STREET, NUMBER, CITY, STATE, ZIP)
POSITION HELD
FROM
TO
A1er A.4.fo SA-L-tr
k-v
b,2%9' f�gr Dfk FL. Ca °
asp 5 02
U
4-a
eRr,.r
'Arird, ,/1t. C14/fhg_ �/y
7fro e. 44.1),,, "Li Qa. f-�r',.�,:: vs4
Es �.�.
f✓.l--1
a -1 lt
f o/W a I I :ils�/ alit- a)
,2 3 (f i ,> r9 /4a re
'� c1 2G/x/ k�
7-/-54'
-/ - 54'
-ls 1(
27. What is your relationship to the applicant? (sole owner, partner, corporate officer, director, stockholder, member or manager)
_SQIE OI A/FJIN
28. If stockholder, number of shares owned beneficially or of record
Percent of outstanding stock owned
29. If partner, state whether ❑ General M Limited
Percent of Partnership Owned
If Limited Liability Company (percent owned)
30. Total amount you will invest in this business, including notes, loans, cash, services or equipment, and operating capital. (Reg. 46-106.1 and Reg. 47-107.1)
i
Amount $_'
31.Identify the sources of all funds you will invest in this business as listed in 30 above. List all bank names,
account numbers and the amount derived from such source. Also identify all persons authorized to sign on,
or who are part owners of said account. (Attach copies of all your notes or loans used in or for this business.)
Amounts
Sources - Account Numbers
Names on accounts or person who can
sign on this account
$ oo
f(lrvfi Ask /.?51ov/31/5//
$, � )r ��
SA/4V,vnA/ 4241/4/441
7 6//,/ c/7Z, Ant A/,,; -r
l'
,
1;t
e000
Del <'A-rn,No 7",t/C //fl'
n
$fl, 7Va �'
A c' -.Z) e
a
Oath of Applicant
I declare under penalty of perjury in the second degree that this application and all attachments are true, correct, and complete to the best
of my knowledge.
Authorized Signature
� , p
Aar'l,�/ Ape_
Title
��i,/E X
Date
C �' - �
951.336
DR 8411 (03/94)
COLORADO DEPARTMENT OF REVENUE
LIQUOR ENFORCEMENT DIVISION
1375 SHERMAN STREET
DENVER CO 80261
LIQUOR LICENSING PROCESSING DOCUMENT
RETAIL LIQUOR &
3.2% BEER LICENSE FEES
1. Name of Applicant(s) (exactly as it appears on state application)
2. Trade Name of Establishment (DBA)
3. Address of Premises (as it appears on the application)
State Sales Tax No
Business Phone '
City
County
DO NOT WRITE IN THIS SPACE
• ALL ANSWERS MUST BE PRINTED IN BLACK INK OR TYPE-
WRITTEN
• APPLICANT MUST CHECK THE APPROPRIATE BOX(ES)
• LOCAL LICENSE FEE $
State
ZIP Code
2320-750 (999) SECTION A FEES
If applicant has a Beer and Wine, or Malt, Vinous and
Spirituous Liquor License, indicate your state Liquor
• License Account No.
❑ Retail Warehouse Storage Permit $50.00
❑ Request to Change, Alter or Modify Premises ....75.00
❑ Addition of Optional Premises to Existing
Hotel/Restaurant $50.00 x Total Fee
❑ Request to Change Corporate or Trade Name ...25.00
❑ Request to Change Location 100.00
❑ Duplicate License 25.00
❑ Subpoena Testimony Fees 100.00
(use license no. 21-94214)
2330-750 (999) SECTION B FEE
If applicant has a 3.2% Beer Retail license, indicate your
• state 3.2% License Account No.
❑ Request to Change, Alter or Modify Premises 75.00
❑ Request to Change Corporate or Trade Name 25.00
❑ Request to Change Location 100.00
❑ Duplicate License 25.00
LIAR
2300
2310
1940
1940
1950
1950
1960
1960
1970
1980
1990
2010
2020.
2030,
2040
1905
2110
SECTION D LIQUOR LICENSE FEES
1970-750 (999) SECTON C
If applicant has a HoteVRestaurant liquor
registering a new manager, indicate your
• License Account No.
❑ Manager's Registration
FEES
license and is
state Liquor
$75.00
2300
2310
2121
2121
2122
2122
2123
2123
2170
❑ Application Fee for New License $450.00
ref Application Fee for Transfer of Ownership 450.00
❑ Retail Liquor Store License (city) 202.50
❑ Retail Liquor Store License (county) 287.50
❑ Liquor Licensed Drugstore (city) 202.50
❑ Liquor Licensed Drugstore (county) 287.50
❑ Beer & Wine License (city) 177.50
❑ Beer & Wine License (county) 262.50
❑ H & R License [Icily ❑ county 326.25
❑ H & R License w/opt Prem ❑ city ❑ county 326.25
❑ Club License ❑ city ❑ county 135.00
❑ Tavern License ❑ city ❑ county 326.25
❑ Arts License CI city city ❑ county '326.25
El Racetrack License Li city ❑ county
❑ Optional Premises License ❑ city ❑ county 326.25
326.25
❑ Retail Gaming Tavern Lic ❑ city ❑county ❑ BWS Special Event Permit each 25.00
❑ Manager's Registration (hotel & restaurant only) .... 75.00
El Extended Hours 170.00
SECTION E 3.2% BEER LICENSE FEES
❑ Application Fee for New License
❑ Application Fee for Transfer of Ownership
❑ Retail 3.2% Beer On Premises - (city)
❑ Retail 3.2% Beer On Premises - (county)
❑ Retail 3.2% Beer Off Premises - (city)
❑ Retail 3.2% Beer Off Premises - (county)
❑ Retail 3.2% Beer On/Off Premises - (city)
❑ Retail 3.2% Beer On/Off Premises - (county)
❑ 3.2% Beer Special Event Permit
DO NOT WRITE IN THIS SPACE - FOR DEPARTMENT OF REVENUE USE ONLY
County
City
Fee paid for 3.2% Beer
State
-750 (999)
City
2180-100 (999)
Cash Fund New us+nse
2300-100
(999)
cash FundTranaer Llamas
2310-100
(999)
Industry Type
County
2190.100 (999)
LIABILITY INFORMATION
Liability Date
State
-750 (999)
Casa Fund raw Liana
2300-100
(999)
License Issued Through
(Expiration Date)
$450.00
450.00
71.25
92.50
71.25
92.50
71.25
92.50
each 10.00
nee : Account Number
Fee paid for Beer, Wine, and Spirituous Liquor
City Managers Reg
1970-755 (999)
2180-100 (999)
Casa Fund Transfer
2310-100
(999)
White Copy - Department of Revenue Canary Copy Liquor Enforcement Division
County
2190-100 (999)
Ext Hours City
2180-100
(999)
Ext Hours County
2190-100
(999)
Pink Copy - Local Authority
Goldeaepant
cn
c
ct
].
CkiLJ
GL
1
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951.33;
18
Denver CO 80261 COLORADO BUSINESS REGISTRATION
I„75 Sienna:: Street
SIDE A
PLEASE PRINT CLEARLY
Check all reasons for submitting this form:
Wage'viahhoony State Sales Tax License
Nx Unemployment Insurance J Other (explain)
. Trade Name Registration
Do You want this number assured to new location? 0 yes , no
+ If trade name registration with the Department of Revenue is required, the information marked Wet, a star 11 hec of
REASON. FOR FILING THIS APPLICATION
'S APplx'atien ❑ Change n Partners ❑ Change n type GI o rers:op
Do you have another business in Colorado' yes ❑ no
IF YES. Registration Account a
REGISTRATION ACCOUNT NUMBER
-39.3//
WI Dine pu 6,amu DO NOT i/RilE IN MIS SPACE
* Indicate Type of Ownership 9 Association ❑ Trust
. i Indwaual ❑ General Partnership ❑ Estate ❑ Nonprofit 501 (C)(3) (Please encase copy or tee IRS later of exemption.)
Limited PartnersnlGovernmentOther Non-Proht O Limited Lamy Company — - -- ---
p 9 Corporation ❑ 9-
'S'
Joint Venture Corporation ❑ Omer
❑ 9
Taxp yer Name (owner. partnersorcorporate name) past, Pest, middle)
8 ble � 2/ h RI
Tr e/Ooin mess fis ij tip
"Ail
* u/x41cnl "•Ail ' 1r-R/��.
Street Address of Principal Place of in Colors
*/0 7EI �v..
Cty
* D .
Slate
* Co
ZIP
*foso57
C �o imy ,
CAI 1A/Cok • a'A a �{/�,p
II bus* is within limits of a city, what city?
,70
Telephone
776 0/%4
I BUSINESS INF
Mailing Address (if di tt l from above) (include um)
City
tale
County
Telephone
I )
Federal Employer I.D. x
Bank Name
Bank Address
Bank Account Number
Payroll Location (List Address )
Telephone
( )
First Day of Payroll (p10/DAY/YR)
/ cis"
What do yQ II and/orservices p/royv)tled? 4444
* 0.0 d g WL��r,Lie J
Do you rent items for
Do you sell woodstoves
30 days or less?O.
Yes o
or fireplace insens? O Yes ar No
It partner is a corporation, give corporation name and Federal Employer Identification Number Number
(FEIN). It there are other partners,
list on separate sheet using the same format.
(1) Owner/Corp. Officers/Posers _
*�'a5/&T— %U/� Al�clF—
Tile
0rvti'E�
Social Securty 4 (Fed. Emp. a if applicable)
C_�
g65
Ad ress (residen e or P O. Box. street, ci state, ZI )
7�.-tt G4Nn cT A4 VADA- 09
K000 c
ep one
(J°?)'3i-6ei8S
y
W
Lu
(2) Owner/Corp. Officers/Panners
Title
Social Security a (Fed. Emp. 4 if applicable)
3
0*
Address (residence or P.O. Box, street, city, state, ZIP)
Telephone
( )
If you acquired the business in whole or in part, complete the following:
Prior nets Name and Address
'el— C..4 -n. /ivo lyr,
Date of Acquisition
4-3-- 75-
Prior Owners UI Tax Account Number
Stree ,.�� /'
% 76 Y / rAJvv/ - %At,"
City
Stat:0
(�(�
ZIP 69,
❑ If Seasonal, mark ❑ JAN ❑ MAR 9 MAY ❑ JULY ❑ SEPT ❑ NOV
each business month. ❑ FEB O APR 9 JUN ❑ AUG ❑ OCT ❑ DEC
x
I—
F
RUNG FREQUENCY: If sales tax collected is I First Day of Business (MO/DAY/YR)
❑ Under g300/month, file quaneny
or more, file monthly I - 6 - qS
PERIOD
BE COVERED
TO
FEES
I-
w
❑ Wholesale only, file annually
I
FROM:
YM'R
TO:
Km
(0280- Trade Name
750) Registration (9991$
//
C� CO
ran
Indicate which applies to you: ❑ Single Event - Pens Covers
❑ Wholesaler 9 Charitable (MO/DAY/YR )
(0020- Sales Tax
810) Deposit�.J (355)5
4
Q•dd
g, Retailer ❑ Multiple Event
`-'\ Location
'
(�' Sales Tax
Q /�
_
/
0
2
FILING METHOD:
Check all taxes to be paid
'7,�
750) License (999)
$ V L�
S
roeis
Ouaneity - All New Accounts
p Monthly - Optional
❑ Weekly - Optional (EFT only)
,P�CSlate and Local Sales J�tetailers Use
PTO/CD/BD $ Wage Withholding
0 County Lodging El Oil & Gas Withholding
Make crux payable to
Dthe epartment of
Revenue
TOTAL
00
$ ‘17
a
THE REVERSE SIDE OF THIS PAGE MUST BE COMPLETED, AND BOTH WHITE PAGES RETURNED
I declare under penalty of perjury in the second degree that the statements made in this application are true and complete to the best of my knowledge.
SIGNi x, q 0wneL,panner o orpor ye Offjepr REQUIRED
* '•''`�fA It J440.1
Title ter'
/ �//slit fir-
Date _ J ��
* !J.
Fl(,`(
OF ICE USE ONLY Account pe Sic Org LC LD
00 SC IA Sig ❑ N TR-1 Date Tech Sip
continue on reverse side of this page.)
Y
SUBLEASE
Sr
THIS SUBLEASE is made this / day of June, 1995, by and between
MANUAL CORRAL and ISABEL TARIN d/b/a COUNTRY DINER, a Colorado
corporation (the "Sublessor") and ROBERT W. KLINE (the "Sublessee").
In consideration of the payment of rent and the performance of the promises
by the Sublessee set forth below, the Sublessor does hereby lease to the Sublessee
the premises situate in the City of Longmont, State of Colorado, more particularly
described in the Lease dated April _, 1993, by and between G.B.G II, Inc., a
Colorado corporation ("Lessor"), and Manual Corral and Isabel Tarin d/b/a Country
Diner ("Lessee"). A copy of the Lease is attached hereto as Exhibit A and by
reference incorporated.
TO HAVE AND TO HOLD the same, with all the appurtenances unto the said
Sublessee from 12 o'clock noon on the [J..* day of CL/ A/6 , 1995, and
thereafter for the remaining lease term specified in the Lease.
Rent and all other terms and conditions specified in the Lease are hereby
incorporated, and the Sublessee shall carry out the terms and conditions of the
Lease as a part of this Sublease.
The Sublessee, in consideration of leasing of the premises, agrees as follows:
1. To pay the rent for the premises above -described.
2. To keep the improvements upon the premises, including sewer
connections, plumbing, wiring and glass in good repair, all at Sublessee's expense,
and at the expiration of this lease to surrender the premises in as good a condition
as when the Sublessee entered the premises, loss by fire, inevitable accident, and
ordinary wear excepted. To keep all sidewalks on and around the premises free and
clear from ice and snow, and to keep the entire exterior premises free from all litter,
dirt, debris and obstructions; to keep the premises in a clean and sanitary condition
as required by the ordinances of the city and county in which the property is situate.
3. To sublet no part of the premises, and not to assign the Sublease or any
interest therein without the written consent of the Lessor and the Sublessor.
4. To use the premises only for lawful purposes.
5. To neither hold nor attempt to hold the Sublessor liable for any injury
or damage, either proximate or remote, occurring through or caused by the repairs,
alterations, injury or accident to the premises, or adjacent premises, or other parts
of the above premises not herein demised, or by reason of the negligence or default
of the owners or occupants thereof or any other person, nor to hold the Sublessor
liable for any injury or damage occasioned by defective electric wiring, or the
951336
breakage or stoppage of plumbing or sewerage upon said premises or upon adjacent
premises, whether by breakage or stoppage results from freezing or otherwise; to
neither permit nor suffer said premises, or the walls or floors thereof, to be
endangered by overloading, nor said premises to be used for any purpose which
would render the insurance thereon void or the insurance risk more hazardous, nor
make any alterations in or changes in , upon, or about said premises without first
obtaining written consent of the Sublessor therefor.
hour.
6. To allow the Sublessor to enter upon the premises at any reasonable
7. To pay all charges for water and water rents, and for heating and
lighting of the building (if improvements exist on the premises) in which said
premises are located.
IT IS EXPRESSLY UNDERSTOOD AND AGREED BETWEEN SUBLESSOR
AND SUBLESSEE AS FOLLOWS:
8. This lease is subject to all the terms and conditions of the Lease for the
premises. Sublessee agrees to be bound by all terms and conditions of the Lease
and agrees not to violate any of the terms and conditions thereof, or cause the
terms and conditions thereof to be violated.
9. No assent, express or implied, to any breach of any one or more of the
agreements hereof shall be deemed or taken to be a waiver of any succeeding or
other breach.
10. If the premises are left vacant and any part of the rent reserved
hereunder is not paid, then the Sublessor may, without being obligated to do so, and
without terminating this Sublease, retake possession of the said premises and rent
the same for such rent, and upon such conditions as the Sublessor may think best,
making such change and repairs as may be required, giving credit for the amount
of rent so received less all expenses of such changes and repairs, and the Sublessee
shall be liable for the balance of the rent herein reserved until the expiration of the
term of this lease.
11. If any part of the rent provided to be paid herein is not paid when due,
or if any default is made in any of the agreements by the Sublessee contained
herein, it shall be lawful for the Sublessor to declare the term ended, and to enter
into the premises, either with or without legal process, and to remove the Sublessee
or any other person occupying the premises, using such force as may be necessary,
without being liable to prosecution, or in damages therefor, and to repossess the
2
951336
premises free and clear of any rights of the Sublessee. If, at any time, this Sublease
is terminated under this paragraph, the Sublessee agrees to peacefully surrender the
premises to the Sublessor immediately upon termination, and if the Sublessee
remains in possession of the premises, the Sublessee shall be deemed guilty of
forcible entry and detainer of the premises, and, waiving notice, shall be subject to
forcible eviction with or without process of law.
12. In the event of any dispute arising under the terms of this lease, or in
the event of non-payment of any sums arising under this lease and in the event the
matter is turned over to an attorney, the party prevailing in such dispute shall be
entitled, in addition to other damages or costs, to receive reasonable attorneys' fees
from the other party.
13. In the event any payment required hereunder is not made within ten
(10) days after the payment is due, a late charge in the amount of five percent (5%)
of the payment will be paid by the Sublessee.
14. This Sublease is made with the express understanding and agreement
that, in the event the Sublessee becomes insolvent, or is declared bankrupt, then in
either event the Sublessor may declare this lease ended, and all rights of the
Sublessee hereunder shall terminate and cease.
15. In addition the terms and conditions heretofore specified pertaining to
default, the following shall constitute an Event of Default under this Sublease:
a. The breach by Sublessee of any obligation, payment, or duty
evidenced by that the Lease or this Sublease.
b. The failure of Sublessee to pay any amount of indebtedness due
and owing to Del Camino, nc. pur t to that Promissory Note of even date
herewith in the amount of $1 . 0 executed by Sublessee for the benefit of Del
Camino, Inc. ion goo • OJ t;7 l'f
16. Sublessee shall indemnify, defend and save harmless the Sublessor from
and against any losses, liabilities, damages, demands, obligations, fines or civil
penalties, together with all costs and reasonable attorneys fees connected therewith,
in any way arising out of, in connection with or related to Sublessee's operation of
the Business or related to this Sublease or the Lease, on or after the closing date,
in the failure or alleged failure of Sublessee to perform the obligations agreed to by
Sublessee as set forth herein, and any claim by any third party based upon the
liability of Sublessee arising by reason of any activity pertaining to the Business, the
Sublease or the Lease.
3
951336
_un l=, ? S __ _5P' _RICE!
-; 2:1111
P. 1G
ID:303-8i1-!181
JUN 05'95 15:5F Nn.^f1? P.r5
THIS LEASE shell be binding on the gartiee, their personal representatives,
successors and assigns.
SUBLESSOR SUBLESSEE:
MANUAL CORRAL AND ISABEL TARIN
D/B/A COUNTRY SDINER, INC.
Br'�UAL kUIIi1I+TIV I{LI11E �'
BY1
4
951336
BILL OF SALE
KNOW ALL MEN BY THESE PRESENTS, That DEL CAMINO,. INC., a
Colorado corporation ("Seller"), for and in consideration of TEN and NO/100THS
DOLLARS ($10.00), to it in hand paid, at or before the ensealing or delivery of these
presents by ROBERT W. KLINE ('Buyer"), the receipt of which is hereby
acknowledged, has bargained and sold, and by these presents does grant and convey
unto the said Buyer, its successors and assigns, the following property, goods and
chattels, to wit:
See Exhibit A attached hereto
located at 10763 Turner Blvd., Unit 1, Longmont, Colorado 80504.
TO HAVE AND TO HOLD the same, unto the said Buyer, his successors and
assigns, forever. The said Seller covenants and agrees to and with the Buyer, his
successors and assigns, to WARRANT AND DEFEND the sale of said property,
goods and chattels, against all and every person or persons whomever. When used
herein, the singular shall include the plural, the plural the singular, and the use of
any gender shall be applicable to all genders.
This Bill of Sale and the conveyance, grant, bargain, sell, transfer, set over,
assignment, release, delivery and conformation made hereunder or made without any
representation, promise or warranty (express or implied and whether dealing with
MERCHANTABILITY, fitness for use or otherwise) by Seller whatsoever.
IN WITNF WHEREOF, the Seller has executed this Bill of Sale this
day of �� , 1995.
DEL CAMINO, INC.
By:tzel
Its: rest ent
STATE OF COLORADO )
Lei
)ss.
• COUNTY OF Lei r •e v )
The foregoing instrument was acknowledged and sworn to before me this
S +h day of 9c.t new , 1996, by E /la ra,tt;.,, President of DEL
CAMINO, INC., a Colorado corporation.
Witness my hand and official seal.
My commission expires:
(SEAL)
9 -a7 -?7 •
Notary Public
��
c ,,
SHARON STU86lERELD
NOUN PURL W OWNS
351336
K -Line Auto Sales PromissonNote
June 5, 1995
K -Line Auto Sales lends to Robert W. Kline the sum of $5,000 to be paid within one
year from above date at 10 percent per annum.
Robert W. Kline Date
4
951336
Pramissary Notts
On this date Y / /4 -s -Shannon Dahman loaned and Robert
Kline borrowed $10,000.00 for the purpose of purchasing a
restaurant and lounge located at the Del Camino Truck Stop
on I-23 and Highway 119.
This is a personal loan g teed by Robert Kline.
Repayment is to begin on June 1, 1996 at the rate of 1
payment per month for $1100.00 for 10 months.
Total amount to be repaid is $11000,00.
'- e -f ?s
Robert K1 no Date Shannon Dahman Date
•
951336
e
L
A
Purchaser Romans Auto Inc.
Pay To The
Order Of
rk 18
******K -Line Auto******
06/05/1995
� `� BANK 0Nh -I• I r X1OO
►' LAKESID LTSLTS
'booed By kkearaleK P..wnenl Syalans Inc. Englewood. Colorado
To CI0W nh 4New Yonn Soul. aulialo, N.Y.
Q
moans? BANKS
fl
' Remitter
Pay
To the *
Order of
Nonvest Bank Colomdo, MA
Lakefwod
7200 Must Alameda
Lakewood, Colorado 80226
HO A SNALJ,.
$ '+5 , 000.00
Drawer. BANK ONE. COLD
2nd Sig Requye9Q'
6,40 sonas4rWegenta
SN1t 1NSD: DAHPI,^.:: Date
RCbERT KLINE
PixcJ al an aloofly Dona mil be
d eee be* ad be replica, el (M
The luxes rmewrme by ors ,
N a* aftqac Y mot weew*a wither
Authwtma rr
951.336
ti
Dollars
Commercial
Federal Bank
Savings Account
Certificate
tt ACCOUNT SUMMARY SECTION
Bonus: ❑ Yes ❑ No Amt.
34 MONTH WORRY FREE CD
rtCCO.'NT MLi(iBE F:
OF EN I NO BALANCE
FIININUM BALANCE
EARNINGS DISTRIBUTION
RATE OF EARNINGS 2.685
ANNUAL PERCENTAGE YIELD
ACCOUNT
ICtDER(S):
15,485.43
QUARTERLY
- 6.630
6.350
ROBERT W FLINE
DATE OF ISSUANCE 06/07/-S
MATURITY DATE 06/07/77
INTEREST CALL DAIi
TERM a YR FIRST YEAR W
GRACE PERIOD 7 DA,L3
MINIMUM ADDITION NONE
SO_
II. GENERAL SECTION. The document addles that the Account Holder holds a savings antdlate account who the apenng 6Wnce and forth, maul
term shown on the documemwet Commercial Federal Bark, a Federal SwigsBark. lithe document is marked *eC foraddllwt5 the Account Holder
may make additions to this court in any amount greater than or equal lo to mlrimun requnmem shown on its document The Sum of this account
eril
us in nothe extended ydbbyyai tool depose_ Charges or Ism or any money due b Fedora Commercial Fedmay bedrrged baccount debt
a yyou have wish
lit EARNINGS SECTION. The account will receive ewrigs a the ram gown, compounded day,unless (1) the mann invadable rate certificate
n wtedi awe a wit initially ern the roe shown on this document and then the rate coil v y in accordance with the tae adpanenl or (2)
the account s load rae and allows add-on deposits In which case the initial depose nil urn to rate shown on the documentya deiposu
wB mown earnings equal to the then aunt w la the depose and the remWrg em of the Maine cote.
M RENEWAL SECTION: TNs account will beautomarically renewed at the cbseolbusisesson the IStialmaturiydaaorthe matuilydaedarybnwal,
tithe then anent rata in •sea the day of maturity, but never less than the than current tae paid on regular savings amen, unless (1) redrawn
wahn the 7 day grace period ocher melody; (2) Com me rcial Federal proses wrelen notice presto the mahsty tae Olathe account wll not be renewed
in which case the account wit be treated as areguW range amid an swam emerge tithe then oat has pad Al mauler airings mums by Commercial Federal.
V. PENALTY CLAUSE SECTION: In the event of any wigdmwal of principal from the mum prior to the initial or renewal maturitydate, the Account
Holder shall lodes an amount, whether awned or not, equal to the graver al (1) three months earrings on the amount withdrawn fd farms bee than
1 yew); (2) six monte earnings on the amount wgMmwn (item is l yeeorggnae. ; or (3) nplaaamentmatwh"rA is del MEd m the dfferencehehwen
the Mgnacen/bas rag and the aanntcertificate raepad byCommerdalFederal Bank pitlehigher) lathe remaining term setaabdontheamount
withdrawn. The peuly we be akuteted according to the Rules of Cate established by the Board of Diectors for the noun dwyiotan and may
reduce the pdnopa balance. A copy of the Rules of Caen was provided to the Account Holder at recount opening, is on record and may be obtained
a any Commercial Federal all a. tat:onus gat I naiad it portal lin of interest all unearned adores:wit be recovered and an Musa {snaky Vill be charged for any early withdrawal.
My withdrawal which reduces the acaurtbalance below the minimum requirement oranychange it the ten wA be considered asawilanwal of the
emu balance and wit be subpar to prescribed early wehdrawa penalise .
No early withdrawal penalties roil be eqpfed when ■ withdrawal a made to Wert a distillation el funds in an Individual Retirement Account, Qualified
Retirement Aomori or Seeded Employee Penesn Account being the pathogen's death or dsabdty. Additionally, ro penalhes coil be appied for
early withdrawal Iron any centime account Blythe death of an account amerces/fro an amen ma a destmlnsd to be epaly Incompetent.
Eunice cadged b the amain may be wthdram at any time wit out peaty.
II any portion of the account s wthdrawn or the account dosed wihn the Idaygraa period, earnings hem the oedliate
aeea•awrtiw meumydaeto the date of withdrawal wit be at the then omens ram paidon the regular usage account Commercial
_esr��i�a i Federal without wreduction the penny.
dhaWhen necessary, dtlhtlsn wit be mode horn the amain wt Nan or the
•e: establshed* neutrino abyUr Board of Directors el balance to meet penally
ttsraamun daatolwh. ms. Thee accountwa.hlminsw.dberoaawwhthe Mn
r+uus ..., wr COe1ERCUL FEDERAL BALK
S
tv
. 5„„ r
11
PI1FWIC
A Federal Sawgs Bank
M
Deposits Insured by the FDIC
NONTRANSFERABLE
• RT-141(REV 059.3)
951.33€
rCommercial
E-Federal Bank
Savings Account
Certificate
L ACCCUASleIpg SECIION—ILi bkWCtiLYH WialU'9 Dyq.LEFlvnt$t;15 II141 F 07th
24 i1UNTH WORRY FREE CD
ACCOUNT NUMBER
OPENING BALANCE 6,000.00
MINIMUM BALANCE 1,000.00
EARNINGS DISFRIBUFION QUARTERLY
RATE OF EARNINGS 4.00 - 5.00
ANNUAL FERCENfAGE YIELD
ACCOUNT
HOLDER(S):
U(11E (IF ISSUANCE 4/17/93
MATURITY DATE -./1'1/95
INIEREST CALL SIMPLE
fERM 2 YR FIRM' YEAR W/D
GRACE PER1U1) 7 U.,'S
MINIMUM ADU11IUN 0.00
HUBERT W. KLINF SOL
IL GENERAL SECTION. The document camas that the Account Hoar hob a smogs certificate am mm with the opening balance am:twig's to all
term shown on this documentwith CommrcialFederal Bark, aFets Saangs Bark lthsdocument Y makadYN•braddtlom, the Amours Hoar
may male additions to this account In any amount greater than orequal to the mwmum requwment shown on the document The term ol the amount
wit not be sanded by an additional repeat Chatges or lee or any money eta Le Commercial Fetal may be chirped to any account you haw wen
us N order to pay the debt
lit EARNINGS SECTION. This amount wit recall anisette rats shown oonpwmded day, unless (I) the account Is e Sala rda awake
n which se l wll ladyern to rra shown on this document and an ere red will varyN accedence web IM Acct S mImea lrem.s y: r (2)
the 'sure a fad rasa and slows add-on deposits in which case the nibs deposit will rem the rate shown on to Sane but additional
In
tea mane earnings squat to the than caned rate for to deposit and the remaining term of the WSW artitaste.
N. RENEWALSECTION: The accountwill beautomatealynnewadathe close olbusmwante irrtialmaturrydauorthe matusitydate of any renewal,
at the then current rate in sited the day of maury, but raw less than the an anent rate paid on regular wings acmwt, unless (I) withdrawn
walla to 7day grace period alurmatey, (2) Commercial Federal provides wrtten flax priortothe manr y dale that theaccount will not be renewed
in which caw the account wit be treated a a regula saw. account and receive semis at the then current has paid on regldr amps abaft
by Commercial Federal .
V. PENALTY CLAUSE SECTION: In the event of any withdrawal of principal from this account pnorto the anal or renewal maturity dale, the Amours
Holder shall (oat an amount, whales earned or nol, equal to the greater d (I) Ile months earrings on the amount withdrawn (l tem is less than
1 Peal; (2) six thongs earnings on the amount withdrawn (if term e l yearorgreated; r(3) replacement oat which adefined athe difference between
to original certificate raleard the current certificate rate pat bbyyCommerdalFedual Bait (if tishigher) for the remaining tea calculated on the amountwithdrawn. The wit be calculated according to the Rules of Cass established by the Board of Directors for the accost classification and may
reduce to principal balance. A copy of the Rules of Class was provided to the Account Holder at account opening b an record and may be obtained
a any Commercial Federal alto. If bonus gil a received n prlai lieu of interest, at unearned interest oil be recovered ad an interest paWywil
be charged for any early wthrawaL
My withdrawal whidt reduces the account balance below the man um requitement or any change is a term wilts cotldered as awltdrawaldthe
rot balance and veil be abed to preeuned say withdrawal pnaGea
No early wit drawal penalise wiled when a withdrawal I -made to Wed a diaion of funds in Si Individualte idual Remed Amount, Quaffed
Retirement Aoy Account or Stalled EncasePension
mbitt
Account blbwng the paucom a death or deabiry. Additionally, no tveil be sired lot
shy wahrawae Item any centime account Meths derh d n amount owner or slur an sown awes is deearW b MIay n poompNMnt
Earnings credited to tit aura may be withdrawn at any fine without penalty.
I any portion of the account is withdrawn or the exeunt dosed *thin the 7day gee period, earnings from the anaol
sarerfe•••„a mattemyale to the date ol wiMrawal veil be age then anent rats paid on ft suit urns accounts by Commec1
_'Ye Federal without
aledudan for penalty.nWWhen necessary, deludes' veil be muds from the amount withdrawn or the
'slum% seisabWed y theiidpa Bawd d D balance to meet
a this daedbeidoty requirements. This n.
�tWbe SNsd Isc idaw wen tsntt
•
•
•i lut�v •
1/447-41F sW" i
e ^aeeeee✓a
A Federal Songs Bark
By
COMMERCIAL FEDEIIAL BANK
Percuvwy
Deposits Insured by the FOICJ
YpMIRAWIFEl1ABLE
RT•1 W (REV OSINg
-4/
951-333
ee
m
N
0
1001
REWARDS BAR & GRILL
10763 TURNER BLVD. 776-0116 _ /� _ 82-544/1070
LONGMONT, CO 80504 DATE l / 030100133
Dear- of flgdsmi.c. s796.
GIrLLARSN
P 387 471 695
RECEIPT FOR CERTIFIED MAIL
NO INSURANCE COVERAGE PROVIDED
NOT FOR INTERNATIONAL MAIL
(See Reverse)
Sent to
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O 'le (Pc 0 e 00
y — � 9AI, O
0 P1 C 14.C:4 Os 14%
_Certti X92 -Pc-,
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c21't�
Special L - C % L
0
OULIFI i�O Ur IJC
�t
/0
Return Receipt e Z
rm 3800, June 1985
to whom and Dat.
Return Receipt sho. .d whom.
Date. and Address o. Oelwery
TOTAL Postage and Fees
Postmark or Date
O CO
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0
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351336
P 387 471 698
RECEIPT FOR CERTIFIED MAIL
NO INSURANCE COVERAGE PROVIDED
NOT FOR INTERNATIONAL MAIL
(See Reverse)
ROBERT W. KLINE
DBA REWARDS BAR AND GRILL
10763 TURNER BLVD.
LONGMONT, CO 80504
Certified Fee
Special Delivery Fee
Restricted Delivery Fee
Return Receipt showing
to whom and Date Delivered
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0
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0
a
Delp did AMP M Nil
vdry
TOTAL Postage and Fees
Postmark or Date
r
SENDER:
• Complete items 1 and/or 2 for additional services.
• Complete items 3, and 4a & b.
• Print your name and address on the reverse of this form so
that we can return this card to you.
• Attach this form to the front of the mailpiece, or on the
back if space does not permit.
• Write "Return Receipt Requested" on the mailpiece next to
the article number.
3. Article Addressed to:
ROBERT W. KLINE
DBA REWARDS BAR & GRILL
10763 TURNER BLVD.
LONGMONT, CO 80504-9578
5. Signature (Addressee)
I also wish to receive the
following services (for an extra
fee):
1. 0 Addressee's Address
2. O Restricted Delivery
Consult postmaster for fee.
4a. Art cle Number
)3F7 t7/ c,f
4b. Service Type
❑ Registered ❑ Insured
Certified ❑ COD
❑ Express Mail ❑ Return Receipt for
Merchandise
7. Date of Deliver
8. Addressee's A
and f is paid)
- is
(Only if requested
*U.S. GPO: Has —Hass . DOMESTIC RETURN RECEIPT
951336
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