HomeMy WebLinkAbout20253170 Fidelity National Title Fidelity National Title Insurance Co.
y 8055 E Tufts Ave,Suite 900
NATIONAL coMMc c,ALsaavcu Denver,CO 80237
Phone:(303)291-9977 Fax:(303)633-7720
Seller's Estimated Settlement Statement
Closing Date: October 31,2025
Disbursement Date: October 31,2025
Proration Date: October 31,2025
Order Number: NCSCO01927
Buyer: Weld County,Colorado,a body corporate and politic under laws of the State of Colorado
1150 0 Street,PO BOX 758
Greeley,CO 80632
Seller: Public Service Company of Colorado,a Colorado corporation
1123 W 3rd Ave
Denver,CO 80223
Property: Vacant Land
CO
Seller
Debit Credit
Total Consideration
Purchase Price 3,120.00
Subtotals 0.00 3,120.00
Balance Due TO Seller 3,120.00
Totals 3,120.00 3,120.00
We/I have carefully reviewed the Settlement Statement and find it to be a true and accurate statement of all receipts and
disbursements made on my account or by me in this transaction and further certify that I have received a copy of the
Settlement Statement.We/I authorize FIDELITY NATIONAL TITLE,NATIONAL COMMERCIAL SERVICES to cause the
funds to be disbursed in accordance with this statement.
SELLER
Public Service Company of Colorado,a Colorado corporation
By:
Ad m Pena,Sr.Manager,Permits and
Right of Way,Excel Services,Inc.,as
Authorized Agent for Public Service
Company of Colorado
FidBf}i y atibnal Title Ins nce
BY:
a Bailey •
Printed on 10/23/20262:41:09 PM NCSC001927
Paae 1 of 1
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Fidelity National Title Insurance Co.
Fidelity National TWO
8055 E Tufts Ave,Suite 900
To NATIONAL COMMe1CIAUlIIV1m! Denver,CO 80237
Phone:(303)291-9977 Fax:(303)633-7720
Buyer's Final Settlement Statement
Closing Date; October 31,2025
Disbursement Date; October 31,2025
Proration Date; October 31,2025
Order Number: NCSC001927
Buyer: Weld County,Colorado,a body corporate and politic under laws of the Stale of Colorado
1150 O Street,PO BOX 758
• Greeley,CO 80632
•
Seller: Public Service Company of Colorado,a Colorado corporation
Right of Way Department,Attn:Senior Manager,1123 W.3rd Ave.
Denver,CO 80223
Lender:
Property: Vacant Land
CO
Buyer
Debit Credit
Total Consideration
Purchase Price 3,120,00
Title I Settlement Charges
Tax Certificate 18.00
Closing Fee 750.00
Owner's Policy Premium 637.00
Coverage; $3,120.00
Version: ALTA Owner's Policy 2021
CO 110.1-06-Deletion-Standard Exceptions-OP 95.00
Recording Charges
Recording Cheeps-Estimate 43.00
Documentary Fee 0,40
Subtotals 4,663.40 0.00
Balance Due FROM Buyer 4,663.40
Totals 4,663,40 4,683.40
Breakaway Signature Page
Ptlnled on 1013012 0 25 1:33:23 PM - NCSCO01927
Pegs 1 of 2
Buyer's Final Settlement Statement
We/I have carefully reviewed the Settlement Statement and find It to be a true and accurate statement of all receipts and
disbursements made on my account or by me In this transaction and further certify that I have received a copy of the
Settlement Statement.Well authorize FIDELITY NATIONAL TITLE,NATIONAL COMMERCIAL SERVICES to cause the
funds to be disbursed In accordance with this statement.
BUYER
Weld Count,Colorad7ady corporate and politic under laws of the State of Colorado
BY: tsZi/
Title:e Y .maiO hewn t ffJYtEy' cui
Fidelity National Title Insurance Co.
BY:
Sonya Bailey
Printed on 10/30/2025 1:33:20 PM NCSCo01027
Peg.2 of
The printed portions of this form,except differentiated additions,have been approved by the Colorado Real Estate Commission(CL8-5-19)
(Mandatory 7-19)
THIS FORM HAS IMPORTANT LEGAL CONSEQUENCES AND THE PARTIES SHOULD CONSULT LEGAL AND TAX OR
• OTHER COUNSEL BEFORE SIGNING.
CLOSING INSTRUCTIONS
Sonya Bailey Date: October ,2025
Fidelity National Title Insurance Co, Order No.: NCSCO01927-SB
8055 E Tufts Ave,Suite 900
Denver,CO 80237
Phone: (303)291-9977 Fax: (303)628-1671
1. PARTIES,PROPERTY. Public Service Company of Colorado,a Colorado corporation,Seller,and Weld County,Colorado,
a body corporate and politic under laws of the State of Colorado, Buyer, engage Fidelity National Title Insurance Co.,
Closing Company,who agrees to provide closing and settlement services in connection with the Closing of the transaction
for the sale and purchase of the Property known as No. Vacant Land, CO,and more fully described in the Contract to Buy
and Sell Real Estate, dated July 14,2025, including any counterproposals and amendments(Contract). All terms of the
Contract are incorporated herein by reference. In the event of any conflict between this Agreement and the Contract,this
Agreement controls,subject to subsequent amendments to the Contract or this Agreement.
2. TITLE COMMITMENT, EXCEPTIONS AND POLICY. Closing Company 0 Agrees ❑ Does Not agree that: upon
completion of a satisfactory title search and examination,it will furnish a Title Insurance Commitment;and it will issue a Title
Insurance Policy provided that all requirements have been fulfilled. Closing Company J Agrees 0 Does Not agree to
furnish copies of Exceptions.
3, INFORMATION, CLOSING, RECORDING. Closing Company is authorized to obtain any information necessary for the
Closing. Closing Company agrees to,deliver and record all documents required or customarily recorded,and disburse all
funds pursuant to the Contract that are necessary to carry out the terms and conditions of the Contract,
4, PREPARATION OF DOCUMENTS, The Closing Company will prepare the necessary documents to carry out the terms
and conditions of the Contract to include:
4.1 Deed. If the deed required In the Contract is a special warranty deed,general warranty deed,bargain and sale deed
(excluding a personal representative's or trustee's deed)or a quit claim deed,the deed will be prepared in accordance
with the Contract by the Closing Company. However,If the Contract requires a different form of deed(e.g.: personal
representative's deed or trustee's deed) or requires that the special warranty deed or general warranty deed list
exceptions other than the "statutory exceptions" as defined In §38-30-113(5)(a), C.R.S., then the Buyer or Seller
must provide the deed or written Instructions for preparation of the deed to the Closing Company fo4r Closing. For
any Buyer or Seller provided deed or written Instructions for preparation of the deed that requires a list of exceptions
other than the"statutory exceptions",the Buyer and Seller will hold the Closing Company harmless for any causes
of action arising out of the use of such deed. The parties acknowledge that the real estate broker working with either
the Buyer or the Seller is not responsible for reviewing or approving any deed not prepared by the real estate broker.
4.2 Bill of Sale. If the transaction Includes the sale of personal property(I.e.within the Contract or a Personal Property
Agreement) from the Seller to the Buyer, Seller and Buyer authorize Closing Company to prepare the bill of sale
conveying the personal property from the Seller to the Buyer as their convener. The Buyer and Seller understand
that the bill of sale Is a legal document and It Is recommended that it be reviewed and approved by their respective
attorneys.
4.3 Closing Statement. Closing Company will prepare and deliver accurate,complete and detailed closing statements
to Buyer,Seller and the real estate brokers working with Buyer and Seller. Closing Statements will be prepared in
accordance with the Contract and written instructions from the Buyer,Seller,lender or real estate brokers so long as
such written instructions are not contrary to the Contract. If the written instructions are contrary to the Contract,the
Buyer and Seller must execute an Agreement to Amend/Extend Contract.
6. CLOSING FEE. Closing Company will receive a fee of Seven Hundred Fifty And No/100 Dollars ($750.00) for providing
closing and settlement services(Closing Fee).
6. RELEASE,DISBURSEMENT. Closing Company is not authorized to release any signed documents or things of value prior
to receipt and disbursement of Good Funds,except as provided In§§10, 11 and 12.
7. DISBURSER. Closing Company must disburse all funds,including real estate commissions,except those funds as may be
separately disclosed in writing to Buyer and Seller by Closing Company or Buyer's lender on or before Closing. All parties
agree that no one other than the disburser can assure that payoff of loans and other disbursements will actually be made.
No.CL8-0-19. CLOSING INSTRUCTIONS
El-Closing Instructions 2019(EIS) Printed: 10.28,25(Q 12:45 PM by SB
COD1139..doc/Updated: 01.21.25 Page 1 CO—FCTV-03000,990240-NCSC001927
CLOSING INSTRUCTIONS
(continued)
8. SELLER'S NET PROCEEDS, Seller will receive the net proceeds of Closing as indicated: ❑Cashier's Check,at Seller's
expense C) Funds Electronically Transferred (wire transfer) to an account specified by Seller, at Seller's expense
m Closing Company's trust account check to Right of Way Department,Attn:Senior Manager,1123 W.3rd Avenue,
Denver,CO 80223
9. WIRE AND OTHER FRAUDS. Wire and other frauds occur in real estate transactions. Anytime Buyer or Seller is supplying
confidential information,such as social security numbers,bank account numbers,transferring or receiving funds,Buyer and
Seller should provide the information in person or in another secure manner.
10. FAILURE OF CLOSING. If Closing or disbursement does not occur on or before Closing Date set forth in the Contract,
Closing Company,except as provided herein,is authorized and agrees to return all documents,monies,and things of value
to the depositing party, upon which Closing Company will be relieved from any further duty, responsibility or liability in
connection with these Closing Instructions. In addition,any promissory note,deed of trust or other evidence of indebtedness
signed by Buyer shall be voided by Closing Company,with the originals returned to Buyer and a copy to Buyer's lender.
11. RETURN OF EARNEST MONEY. Except as otherwise provided In§ 12, (Earnest Money Dispute), if the Earnest Money
is being held by Closing Company and has not already been returned following receipt of a Notice to Terminate or other
written notice of termination, Closing Company must release the Earnest Money as directed by the written mutual
instructions from the Buyer and the Seller. Such release of Earnest Money must be made within five(5)days of Closing
Company's receipt of the written mutual instructions signed by both Buyer and Seller,provided the Earnest Money check
has cleared.
12. EARNEST MONEY DISPUTE. In the event of any controversy regarding the Earnest Money (notwithstanding any
termination of the Contract),provided Closing Company Is holding the Earnest Money, Closing Company is not required to
take any action. Closing Company,at its option and sole subjective discretion,may: (1)await any proceeding,(2)interplead
all parties and deposit Earnest Money into a court of competent jurisdiction and recover court costs and reasonable attorney
and legal fees,or(3)provide notice to Buyer and Seller that unless Closing Company receives a copy of a Summons and
Complaint or Claim (between Buyer and Seller) containing the case number of the lawsuit(Lawsuit)within one hundred
twenty(120)days of Closing Company's notice to the parties, Closing Company is authorized to return the Earnest Money
to Buyer. In the event Closing Company does receive a copy of the Lawsuit, and has not Interpled the monies at the time
of any Order,Closing Company must disburse the Earnest Money pursuant to the Order of the Court.
13. SUBSEQUENT AMENDMENTS. Any amendments to,or termination of, these Closing Instructions must be in writing and
signed by Buyer,Seller and Closing Company.
14. CHANGE IN OWNERSHIP OF WATER WELL: Within sixty (60)days after Closing, Closing Company will submit any
required Change In Ownership form or registration of existing well form to the Division of Water Resources in the Department
of Natural Resources(Division),with as much Information as is available.Closing Company Is not liable for delaying Closing
to ensure Buyer completes any required form.
15. FIRPTA AND COLORADO WITHHOLDING. The Internal Revenue Service and the Colorado Department of Revenue may
require Closing Company to withhold a substantial portion of the proceeds of this sale when Seller is either of the following:
(a) a foreign person, or(b)will not be a Colorado resident after Closing. Seller should inquire of Seller's tax advisor to
determine if withholding applies or if an exemption exists.
15.1 FIRPTA. Seller agrees to cooperate with Buyer and Closing Company to provide any reasonably requested
documents to determine Seller's foreign person status. If withholding is required,Seller authorizes Closing Company
to withhold any required amount from Seller's proceeds and remit it to the Internal Revenue Service.
15.2 Colorado Withholding. Seller agrees to cooperate with Closing Company to provide any reasonably requested
documents to determine Seller's status. If withholding Is required under Colorado law, Seller authorizes Closing
Company to withhold any required amount from Seller's proceeds and remit it to the Colorado Department of
Revenue,
16. ADDITIONAL PROVISIONS. (The following additional provisions have not been approved by the Colorado Real Estate
Commission.)
17. COUNTERPARTS. This document may be executed by each party,separately,and when each party has executed a copy,
such copies taken together shall be deemed to be a full and complete contract between the parties,
18. BROKER'S COPIES. Closing Company must provide, to each real estate broker in this transaction, copies of all signed
documents that such brokers are required to maintain pursuant to the rules of the Colorado Real Estate Commission.
Closing Company is authorized by both Buyer and Seller to deliver their respective Closing Statement to one or both real
estate brokers Involved in this transaction.
19. NOTICE,DELIVERY AND CHOICE OF LAW.
No.CL8.5.19. CLOSING INSTRUCTIONS
El-Closing Instructions 2019(EIS) Printed: 10.28.25 @ 12:45 PM by Se
C0o1130,doc/Updated: 01.21.25 Page 2 CO—FCTV-03000 990240-NCS0001927
CLOSING INSTRUCTIONS
(continued)
19.1. Physical Delivery and Notice. Any document,or notice to another party must be in writing,except as provided in
§19.2 and is effective when physically received by such party.
19.2 Electronic Notice. As an alternative to physical delivery,any notice,may be delivered in electronic form to another
party at the electronic address of the recipient by facsimile,email or DocuSign.
19.3. Electronic Delivery. Electronic Delivery of documents and notice may be delivered by: (1) email at the email
address of the recipient, (2)a link or access to a website or server, provided the recipient receives the information
necessary to access the documents or(3)facsimile at the facsimile number(Fax No.)of the recipient.
19.4. Choice of Law. These Closing Instructions and all disputes arising hereunder are governed by and construed in
accordance with the laws of the State of Colorado that would be applicable to Colorado Residents who sign a contract
in Colorado for real property located in Colorado.
END OF INSTRUCTIONS
IN WITNESS WHEREOF,the undersigned have executed this document on the date(s)set forth below.
SELLER(S):
Public Service Company of Colorado,a Colorado corporation
By:
Date
Ad m Pena,Sr.Manager,Permits and // 23 ht. 3
Right of Way, Excel Services, Inc.,as Address: !/
Authorized Agent for Public Service 7),(, ,c/'/ CO' e--a 22 3
Company of Colorado
Phone:
Email: 4/a1 , .G#tC4 (.2 �• re
BUYER(S): "V
Weld County,Colorado,a body corporate and politic under
laws of the State of Colorado
BY: Date
Name:
Title:
Address:
Phone:
Email:
No.CL8-5-19. CLOSING INSTRUCTIONS
El-Closing Instructions 2019(EIS) Printed: 10.28.25 @ 12:45 PM by SB
COD1139.doc/Updated: 01.21.25 Page 3 CO—FCTV-03000.990240-NCSC001927
CLOSING INSTRUCTIONS
(continued)
19.1. Physical Delivery and Notice. Any document,or notice to another party must be In writing, except as provided in
§19.2 and Is effective when physically received by such party.
19.2 Electronic Notice, As an alternative to physical delivery,any notice,may be delivered in electronic form to another
party at the electronic address of the recipient by facsimile, email or DocuSign.
19,3. Electronic Delivery. Electronic Delivery of documents and notice may be delivered by: (1)email at the email
address of the recipient, (2)a link or access to a website or server, provided the recipient receives the information
•
necessary to access the documents or(3)facsimile at the facsimile number(Fax No.)of the recipient.
19.4. Choice of Law, These Closing Instructions and all disputes arising hereunder are governed by and construed in
accordance with the laws of the State of Colorado that would be applicable to Colorado Residents who sign a contract
in Colorado for reel property located in Colorado.
END OF INSTRUCTIONS
IN WITNESS WHEREOF,the undersigned have executed this document on the date(s)set forth below.
SELLER(S):
Public Service Company of Colorado,a Colorado corporation
Date
By:
Adam Pena,Sr.Manager, Permits and
Right of Way,Excel Services, Inc„as Address:
Authorized Agent for Public Service
Company of Colorado
Phone:
Email:
BUYER(S):
Weld County,Colorado,a body corporate and politic under
laws of the ate of Colorado
�,. I i 15 J 2D 25
BY:. "`— Date
Name: rr L
Title: iavl�r, Address: I ( 5 Q 0 Street
o L'ax 758 Creaky, co eo1R3
Phone: CI 70"y 0 0^ 4.3 qc
Email: CI ��tt3�� U�E'�C •Bay
No,CLS-6-13. CLOSING INSTRUCTIONS
El-Closing Instructions 2019(EIS) Printed: 10 26,25(a?12:45 PM by SB
C001139.doc/Updated: 01 21.25 Page 3 CO—FCTV-03000.990240-NCSC001927
CLOSING INSTRUCTIONS
(continued)
Closing Company: Fidelity National Title Insurance Co.
Escrow Officer
Authorized Signature Title Date
Address: 8055 E Tufts Ave,Suite 900
Denver,CO 80237
Phone No.: (303)291-9977
Fax No.: (1031633-7720
Email: Sonya,Balley@fnf,com
No.CL8.6.19. CLOSING INSTRUCTIONS
El-Closing Instructions 2019(EIS) Printed: 10.28.25 It 12:45 PM by SB
C001139,doc/Updated: 01.21.25 Page 4 CO--FCTV-03000,990240-NCSC001927
Fidelity National Ti•
tle TAX, WATER AND
ASSESSMENT AGREEMENT
i40 NATIONAL COMMERCIAL SERVICES
Order No.: NCSC001927-SB
Closing Date: October ,2025
Property; Vacant Land,CO
THE UNDERSIGNED,have read and understand the following,and by their signatures below,agree to the following:
I. REAL AND PERSONAL PROPERTY TAXES AND TAX PRO-RATIONS
• Purchaser has received, as of this date October_, 2025, a credit from Seller for the taxes for the current year as
disclosed on the Purchaser and Seller settlement statements, This proration is based on:
Other: Estimated Taxes for the current year based on No proration of taxes per Section 4,6(a)of the Purchase and
Sale Agreement.
Seller warrants that the above property IS NOT subject to a pending tax protest or appeal. Seller further warrants that
special assessments, if any, affecting subject property are paid in full,except as reflected on the statement of settlement.
SELLER AND PURCHASER AGREE THAT THE ABOVE REFERENCED PRORATION SHALL BE CONSIDERED A
FINAL SETTLEMENT,AND AS SUCH,PURCHASER AGREES TO PAY ALL TAXES FOR THE CURRENT YEAR.
II. WATER,SEWER AND STORM DRAINAGE
Vacant Land
Closing Agent has NOT collected funds for final billing. CLOSING AGENT IS HEREBY RELIEVED OF AND HELD
HARMLESS FROM ANY LIABILITY WITH REGARD TO SAID ITEMS.
IN THE EVENT THAT FINAL BILL EXCEEDS THE ESCROWED AMOUNT, ANY ADDITIONAL CHARGES ARE THE
RESPONSIBILITY OF THE SELLER AND/OR BUYER.
Transfer fees to be paid by the 0 Seller❑Purchaser 0 Not applicable.
III. IRRIGATION/DITCH WATER
Not Applicable
IV. OWNER'S/CONDOMINIUM ASSOCIATION/METRO DISTRICT
Seller and Purchaser hereby agree that there is NO active Owner's Association/Metro District and/or the Owner's
AssociatIon/Metro District is voluntary. Fidelity National Title Insurance Co. has not collected or prorated any dues or
assessments for this transaction, CLOSING AGENT IS HEREBY RELIEVED OF AND HELD HARMLESS FROM ANY
LIABILITY WITH REGARD TO SAID ITEMS.
With regards to the closing of Vacant Land, CO (Property Address), both the Buyer(s)and Seller(s)fully understand that the
telephone company,gas,electric,propane and the present hazard insurance agency will not be notified by the escrow agent.
PURCHASER AND SELLER HAVE REVIEWED THE ABOVE REFERENCED HOMEOWNER'S ASSOCIATION
INFORMATION AND HEREBY AGREE THAT IT REPRESENTS A COMPLETE AND ACCURATE LIST OF
ASSOCIATIONS/SUB-ASSOCIATIONS FOR THE ABOVE REFERENCED PROPERTY. FIDELITY NATIONAL TITLE
INSURANCE COMPANY, FIDELITY NATIONAL TITLE INSURANCE CO. IS HEREBY RELEASED OF ANY LIABILITY
WITH REGARD TO ANY ASSOCIATIONS/SUB-ASSOCIATIONS NOT LISTED ABOVE. FIDELITY NATIONAL TITLE
INSURANCE COMPANY, FIDELITY NATIONAL TITLE INSURANCE CO. IS HEREBY RELEASED OF ANY LIABILITY
WITH REGARD TO ANY COVENANT VIOLATIONS DISCLOSED OR NOT DISCLOSED BY THE SELLER OR
MANAGEMENT COMPANY.
Tax Water and Assessment Agreement(Legal) Printed: 10.23.25 @ 04:34 PM by SB
COD1350.doc/Updated; 10.00,25 Page 1 CO—FCN-03000,990240-NCSC001027
TAX WATER AND ASSESSMENT AGREEMENT
(continued)
IN WITNESS WHEREOF,the undersigned have executed this document on the date(s)set forth below.
BUYER(S):
Weld County, Colorado,a body corporate and politic under
laws of th- State of Color do �l' 5-,�a
BY: �� � �'' Date
Name: )err
Title:L ' Id C�oun�-v O' ;i vvier ChAi
SELLER(S):
Public Service Company of Colorado,a Colorado
corporation
Date
By:
Adam Pena,Sr.Manager, Permits and
Right of Way, Excel Services,Inc„as
Authorized Agent for Public Service
Company of Colorado
•
•
Tax Water end Assessment Agreement(Legal) Printed: 10,23.25 Op 04:34 PM by SB
COD1355,doc/Updated: 10.05,25 Page 2 CO—FCTV-03000.990240-NCSC001927
TAX WATER AND ASSESSMENT AGREEMENT
(continued)
IN WITNESS WHEREOF,the undersigned have executed this document on the date(s)set forth below.
BUYER(S):
Weld County,Colorado,a body corporate and politic under
laws of the State of Colorado
BY: Date
Name:
Title:
SELLER(S):
Public Service Company of Colorado,a Colorado
corporation
rdt t d"
Date
By:
dam Pena,Sr.Manager, Permits and
Right of Way, Excel Services, Inc.,as
Authorized Agent for Public Service
Company of Colorado
Tax Water and Assessment Agreement(Legal) Printed: 10.23.25 @ 04:34 PM by SB
COD1356.doc/Updated: 10.08.25 Page 2 CO—FCTV-03000.990240-NCSC001927
AFFIDAVIT
STATE OF CC)lvVT.a. Order No.: NCSCO01927-SB
COUNTY OF 7).1,1,�G✓�
OWNER(S): Public Service Company of Colorado, a Colorado corporation
COMMITMENT NO. (The "Commitment"): NCSCO01927
PROPERTY: Vacant Land, CO
LEGAL DESCRIPTION (The"Property"including any buildings and other improvements there):.
SEE EXHIBIT"A"ATTACHED HERETO AND MADE A PART HEREOF
The undersigned Owner(s) ("Owner") of the above described Property, makes the following statements and
representations to Fidelity National Title Insurance Company:
1. OWNERSHIP: Public Service Company of Colorado,a Colorado corporation is/are the owner of the Property.
2. POSSESSION: Owner(s) has not leased, permitted or granted to any other person or entity, either verbally or
in writing, any right to use, possess, occupy or inhabit the Property or any part thereof for any purpose, and no
other person has or claims any present right to use or possess the Property except as set forth in the
Commitment and in paragraph ten (10).
3. EASEMENTS, RIGHTS OR CLAIMS: Owner(s)knows of no claims, rights, interest, easements, rights of way,
liens, agreements, options, contracts, or other matters affecting the Property whether verbal, written,
unrecorded, or appearing in the public records except as set forth in the Commitment and in paragraph
ten(10).
4. MECHANICS' LIEN: Owner(s) has paid, in full, for all labor, materials and services provided for any repairs,
maintenance, remodeling, renovation or other types of construction for improvements or additions on or to the
Property. Owner(s) is aware of no bills, invoices or accounts for labor, material or services rendered on the
Property which are claimed to be unpaid or for which claim of payment has been made.
5. FINANCING STATEMENTS: There are no chattel mortgages, financing statements, retention of title
agreements or any other interests affecting any fixtures, equipment or other improvements on the Property,
except as set forth in the Commitment and in paragraph ten (10).
6. As a result of Closing Company maintaining its general escrow accounts with the depositories, Closing
Company will deposit and hold Escrow Funds in an escrow account, together with similar funds from other
transactions, at a FDIC insured trust company, bank, savings bank, savings association, or other financial
services entity, Closing Company may receive certain financial benefits such as an array of bank services,
accommodations, loans or other business transactions from the depositories ("collateral benefits"). All
collateral benefits shall accrue to the sole benefit of Closing Company and Closing Company shall have no
obligation to account to the parties to this escrow for the value of any such collateral benefits. Unless
specified otherwise, it is understood and the parties hereby consent that any interest earned, or other financial
benefits received, on such account(s) shall be retained by the Closing Company. Upon request, deposits
made to the Closing Company may be invested on behalf of any party or parties hereto; provided that any
direction to the Closing Company for such investment shall be expressed in writing and the Closing Company
shall receive at the time of such request the taxpayer's identification number and requisite investment forms.
The Closing Company shall charge a fee, not to exceed Seventy-Five And No/100 Dollars ($75.00), to invest
funds in an interest-bearing account.
7. RELIANCE: Owner(s) understands that Fidelity National Title Insurance Company will rely on the statements
herein to issue its policy or policies of title insurance on the Property, and agrees to indemnify and hold
harmless Fidelity National Title Insurance Company from any loss or damage it may sustain, including but not
limited to reasonable attorney's fees and all court costs, should any of the statements herein be incorrect.
Affidavit(Owner-Borrower-NCS) Printed: 10.28.25 @ 01:58 PM by SB
COD1371.doc/Updated: 10.08.25 Page 1 CO—FCTV-03000.990240-NCSCO01927
AFFIDAVIT
(continued)
8. NEW CONSTRUCTION: There has been no new construction on the Property in the past six(6) months, nor
are there any plans for the commencement of any new construction unless indicated below:
9. The undersigned covenants and agrees that there are NO defects, lien encumbrances, adverse claims or
other matters subsequent to the effective date of the herein referenced Title commitment and prior to the date
the proposed insured acquires for value of record the estate covered therein.
10. EXCEPTIONS: the only exceptions to the above statement are:
items shown on Commitment,Buyer's right to use or occupy the Property and Buyer's potential construction
IN WITNESS WHEREOF, the undersigned have executed this document on the date(s)set forth below.
Public Service Company of Colorado, a Colorado
corporation
By:
,,,,,Z7-:--.7.Z.. .7.
Adam Pena, Sr. Manager, Permits and
Right of Way, Excel Services, Inc., as
Authorized Agent for Public Service
Company of Colorado
STATE OF-61-61v
COUNTY OF TD.r t .v
The foregoing instrument was acknowledged before me this 2...--71`" day of October, 2025, by Adam Pena,
Sr. Manager, Permits and Right of Way, Excel Services, Inc., as Authorized Agent for Public Service Company of
Colorado, a Colorado corporation
Notar blic
My Commission Expires: id/Z 5 Lot 7
(SEAL)
Jeremy Bourg
NOTARY PUBUC
STATE OF COLORADO
NOTARY ID#20114068516 i
MY COMMISSION EXPIRES 10/25/2027
Affidavit(Owner-Borrower-NCS) Printed: 10.28.25 @ 01:58 PM by SB
COD1371.doc/Updated: 10.08.25 Page 2 CO--FCTV-03000.990240-NCSC001927
EXHIBIT "A"
Legal Description
A tract or parcel of land No. RWE-04 of the Department of Transportation, State of Colorado, Project Code 24989,
Project Number STU C030-085, containing 3,095 square feet(0.071 acres), more or less, being a part of the
Northwest One-Quarter(NW1/4)of Section 30,Township 5 North, Range 67 West of the Sixth Principal Meridian
(6 P.M.), County of Weld, State of Colorado, being a portion of that Warranty Deed filed in the Weld County Clerk
and Recorders office under Reception No. 1804393, Dated September 26, 1979 and being more particularly
described as follows:
COMMENCING at the Northwest Corner of said Section 30;
Thence South 68°55'31"East, a distance of 138.94 feet, to a point on the Easterly line of said Warranty Deed
description and being the POINT OF BEGINNING
1.Thence departing said Easterly line South 89°58'57"West, a distance of 60.49 feet;
2.Thence South 55°59'39"West, a distance of 35.78 feet;
3.Thence South 00°24'36"West, a distance of 60.00 feet,to a point on the Southerly line of said Warranty Deed
description;
4. Thence along said Southerly line,South 89°58'57"West, a distance of 10.00 feet, to a point on the Easterly
Right-of-Way line of Weld County Road 13, and described in Road Viewers report filed in the Weld County Clerk
and Recorders office under Reception No.46959, dated February 13, 1893;
5.Thence departing said Southerly line and along said Easterly Right-of-Way line, North 00°24'36" East, a
distance of 100.00 feet,to a point on the Southerly Right-of-Way line of Weld County Road 54 and described in
Quit Claim Deed filed In the Weld County Clerk and Recorders office under Reception No.56647,dated June 18,
1895;
6.Thence departing said Easterly Right-of-Way line and along said Southerly Right-of-Way line. North 89°58'57"
East,a distance of 100.00 feet,to a point on the Easterly line of said Warranty Deed;
7. Thence departing said Southerly Right-of-Way line and along said Easterly line, South 00'24'36"West, a
distance of 20.00 feet to the POINT OF BEGINNING.
For Informational Purposes Only
TAX I.D. No.: R0271087/095730000037
Affidavit(Owner-Borrower-NCS) Printed: 10.28.25 @ 01:58 PM by SB
COD1371.doc/Updated: 10.08.25 Page 3 CO—FCTV-03000.990240-NCSCO01927
After recording,return to:
QUITCLAIM DEED IN LIEU OF CONDEMNATION
PUBLIC SERVICE COMPANY OF COLORADO, a Colorado corporation whose street
address is Right of Way Department, Attn: Senior Manager, 1123 W 3rd Ave, Denver, CO 80223
("Grantor"), for Ten Dollars ($10.00) and other valuable consideration, in hand paid,hereby sells
and quitclaims, in fee simple, to Weld County, Colorado, a body corporate and politic under the
laws of the State of Colorado("Grantee")whose address is, 1150 0 Street,P.O.Box 758,Greeley,
Colorado 80632, the real property in Weld County, Colorado, described in Exhibit 1 attached
hereto and incorporated herein,with all its appurtenances(the"Property"),but EXCEPTING AND
RESERVING UNTO GRANTOR and its successors and assigns the easements, rights and
interests in the Property ("Reserved Interests")that are described on Exhibit 2 attached hereto and
incorporated herein.
By accepting and recording this deed, Grantee further agrees with Grantor as follows:
(1)Pursuant to Article 6 of Title 38, Colorado Revised Statutes, Grantee has the
power of eminent domain (otherwise referred to as condemnation power) to acquire private
property for public purposes. Grantee has determined that acquisition and development of
the Property is necessary and is in the public interest and necessary for public use. In lieu of
requiring Grantee to exercise its condemnation power to acquire the Property, Grantor has
agreed to convey the Property to Grantee and Grantee has agreed to acquire the Property,
upon all of the terms, covenants and conditions of this Quitclaim Deed. Grantee hereby
stipulates and agrees that the Property conveyed herein shall be used by Grantee for a public
purpose and that all parcels created by this conveyance(including the Property and any larger
parcel from which the Property is subdivided) are properly created and conform to all
applicable laws, ordinances and regulations regarding the subdivision of property.
(2)The Property is sold by Grantor and acquired by Grantee "As-Is,Where-Is, With
All Faults" with no right of set-off or reduction in the purchase price and without
representation, covenant, or warranty of any kind, express or implied, either oral or written,
statutory, common law or otherwise, made by Grantor or any agent or representative of
Grantor with respect to the physical or structural condition of the Property or with respect to
the compliance of the Property or its operation with any laws, ordinances or regulations of
any government or other body (except as provided in the last paragraph of this Section 2).
Grantee acknowledges and agrees Grantor has not made and does not make, and Grantee
waives and releases, any representations, warranties or covenants of any kind or character
whatsoever, whether express or implied, with respect to warranty of condition, safety,
income potential, operating expenses, uses, habitability,tenant ability, or suitability for any
purpose, merchantability, or fitness of the Property for a particular purpose, all of which
warranties Grantor hereby expressly disclaims. Further, Grantor has not made any
representation or warranty regarding any matter or circumstance relating to Environmental
Law, the release of Hazardous Substances in, on or under the property, or the protection of
human health, safety, natural resources or the environment, or any other environmental
condition of the property, and nothing in this deed or any related agreement shall be
construed as such a representation or warranty,and Grantee shall be deemed to be taking the
assets"as is"and"where is"with all faults for purposes of the environmental condition, and
Grantee has relied entirely upon information and knowledge obtained from its own
investigation, experience, or personal inspection of the Property.
(3)Grantee expressly assumes all environmental and other liabilities with respect to
the property including but not limited to any liability of any kind arising in any way from the
presence or historic operations on the property and any remaining environmental conditions
that could potentially impact the soil or groundwater, soil gas at,under or above the property
whether such liability is imposed by statute or derived from common law, including but not
limited to liabilities arising from environmental law. To the extent permitted by Colorado
law, Grantee, its successors, assigns, agents and representatives hereby agree to hold
harmless, waive, release and forever discharge Grantor, its parent, affiliates, subsidiaries,
officers, directors, employees shareholders, contractors, successors, agents insurers, and
representatives from all Liabilities, whether known or unknown, to the extent caused by or
arising out of or resulting from the environmental condition of the Property or arising under
Environmental Laws whether such Liabilities are imposed by statute, or derived from
common law,and all other comparable federal, state or local environmental, conservation or
protection laws, rules or regulations relating to Hazardous Substances on, under, or
originating from the real property or interest being conveyed following the date hereof.
Grantee hereby further releases and discharges Grantor from any and all Liabilities which
Grantee may have against Grantor in connection with or arising out of the environmental
condition of the Property as of the date hereof.
(4)In this deed the following capitalized terms have the following meanings:
Environmental Law. Any federal, state, or local laws (including common laws),
statutes, regulations, ordinances, codes, orders, or decrees issued or promulgated by any
governmental authority relating to the prevention of pollution, preservation and
restoration of environmental quality, protection of human health, the environment and
natural resources (including air, surface water, groundwater or land), or the release, use,
generation, handling, storage, treatment, transportation, or disposal of Hazardous
Substances, including, without limitation, the Toxic Substances Control Act (15 U.S.C.
§ 2601, et seq.), the Comprehensive Environmental Response, Compensation, and
Liability Act (42 U.S.C. §§ 9601 et seq.), the Solid Waste Disposal Act, as amended by
the Resource Conservation and Recovery Act (42 U.S.C. § 6901, et. seq.) the Hazardous
Material Transportation Act, (49 U.S.C. § 6901, et seq.), the Federal Water Pollution
Control Act,(33 U.S.C. § 1251,et seq.),and the Clean Air Act,(42 U.S.C. § 7401,et seq.),
and applicable state counterparts, and their implementing regulations, all as amended.
Hazardous Substances. Any pollutants, contaminants, toxic or hazardous or
extremely hazardous substances, materials, wastes, constituents, compounds, chemical Is,
or other materials that are listed in, regulated by, or may form the basis of any liability
under, any Environmental Law.
Liability or Liabilities. Any and all, direct or indirect, demands, claims, notices of
violations, notices of probable violations, filings, investigations, administrative
proceedings, actions, causes of action, suits, other legal proceedings, judgments,
assessments, damages, deficiencies, taxes, penalties, fines, obligations, responsibilities,
liabilities,payments,charges,losses,costs,and expenses of any kind or character(whether
known or unknown, fixed or unfixed, conditional or unconditional, based on negligence,
strict liability, or otherwise, choate or inchoate, liquidated or unliquidated, secured or
unsecured, accrued, absolute, contingent, or other legal theory), including, any legal or
other costs and expenses incurred in connection with investigating or defending any of the
foregoing, and all amounts paid in settlement of any of the foregoing.
Signed and delivered as of djij,, ,2025.
PUBLIC SERVICE COMPANY OF
COLORADO, a Colorado corporation
By
Adam Pena
Senior Manager, Permits and Right of Way
Xcel Energy Services, Inc., as
Authorized Agent for Public Service
Company of Colorado
STATE OF COLORADO )
CITY AND ) ss.
COUNTY OF DENVER ) /�j /
The foregoing instrument was acknowledged before me this Z-7/day of (/GO L►;-
2025,by Adam Pena as Senior Manager, Permits and Right of Way,Xcel Energy Services,
Inc.,as Authorized Agent of Public Service Company of Colorado, a Colorado corporation.
My commission expires: /0/2 S. 2o2-i
Witness my hand and official seal. 64
Jeremy Bourg Not t
NOTARY PUBLIC
tiY
STATE OF COLORADO
NOTARY ID#20114068516
MY COMMISSION EXPIRES 10/25/2027
Exhibit 1 to Quitclaim Deed
(Property Legal Description)
EXHIBIT"A"
PROJECT CODE: 24989
PROJECT NUMBER:STU C030.085
PARCEL NUMBER:RAVE-04
DATE:April 04,2024
LEGAL DESCRIPTION
Atract or parcel of lend No.RWE-ai of the Department of Transportation,State of Colorado,Project Coda 24989,Project
Number STU C030-065,containing 3,095 aware feet{0.071 acres),more or less,being a part of the Northwest One-Quarter
4NW1J4)of Section 30,Township 9 North,Range 67 West of the Sixth Principal Meridian(6 P.M.),County of Weld,State of
Cobrado,beings portion of that warranty deed Bled In the Weld County Clark and Recorders office under reception No,
1804393,Dated September 25,1979 and being more particularly described as follows;
COMMENCING at the Northwest-Comer of said Section 30;Thence South 6E755'31"East,a distance of 138,94 feet,to a point
oath*Easterly tine of sold warranty deed description and being the POINT OF BEGINNING,
1. Thence departing said Easterly line South BB'Sl'S7"West,a distance of 60.4.9 feet:
2, Thence South 55'S9'39"Went,a distance of 35.78 feet;
3, Thence South 0014'3S West,a distance of BOA)feet,to a point on the Southerly lira_of said warranty deed
description;
4. Thence along said Southerly lino,South 89"56"S1"West,a distance of 10.00 feet,to a point on the Easterly Right-of-
Way line of Weld County Road 13,sad debtribed in Road Viewers report filed in the Weld County Clerk and Recorders
office under reception No,46959,dated February 13,1893;
5. Thence departing said Southerly line and along said Easterly Right-of-Way line,North 00-24'3S'East,a dlstanoeof
100.00 feet to a paint on the Southerly Right-ef•Way line of Weld County Rood 54 and described in Quit Claim deed
filed in the Weld County Clerk and Recorders office under reception No.56647,dated rune 1e,1895;
6. Thence departing said Easterly Right-of-Way line end along said Southerly Right-of•Way line,North 80 58'S7"East e
distance of 100.00 feet,to a point on the Easterly irate of said warranty deed;
7. Thence departing said Southerly Right-of:Waytine end along sold Easterly line,South 00'24'35'WpSS,a distance of
20.00 feet to the POINT OF BEGINNING.
The ebmre-described pc red contains 3,095 sf.(0.071 ac.),more or krss.
Basis of Bearings:The North line of the Northwest Ono Quarter of Section 30,Township S North,Re age 67 West of the Sixth
Principal Meridian,County of Weld,State of Colorado.From the Northwest Corner of said section 30,being monemented by A
No.6 mbar with a 2,5-Inch aluminum cap stamped LS 17652,In a monument box at die West end,to the North One-Quarter
comer of said section 30,being monumented by A No,6 rebar with a 25-inch aluminum OAP stomped IS 17662,Ina Monument
box at the East End,as Bearing North 89'5817J'East,a distance of 2562,37 feet,being a Grid Bearing of the Colorado State
Plane Coordinate System,North Zona,North American Datum 1983/2011,with ail other bearings contained hereto relative
thereto,
For and on behalf of Wald County n
Daniel R.Holmes,Pis 30213 .K'�•p•.". y',,. i'4,
(WO)304-6446 ¢, •, r
Weld County Public Works Dept. ".
11.11 H Street •
=
Greeley,C080032 > t p
"�k AC LAW ''f 1
Exhibit 2 to Quitclaim Deed
(Reserved Interests)
Grantor(also referred to as "PSCo") reserves to itself and its successors and assigns the following
Reserved Interests:
1. A perpetual, non-exclusive easement for the transmission and distribution of
electricity, for the transmission and distribution of natural gas and communication
signals, and the repair, like kind replacement and maintenance of existing utility
facilities, both overhead and underground, including poles, pipes and other supports
of whatever materials; together with braces, guys, anchors, cross-arms, cables,
conduits,wires, conductors,manholes,transformers, and other fixtures, devices,and
appurtenances used or useful in connection therewith (collectively the "Facilities")
on, over,under, and across the following described premises (the "Easement Area"):
The Property identified in Exhibit A to the Quitclaim Deed
2. All of Grantor's right, title and interest in and to the existing Facilities and any future
Facilities.
3. The right and authority in PSCo, its successors, licensees, lessees, contractors, or
assigns, and its and their agents and employees to (1) enter at all times upon said
Property to survey, mark and sign the Easement Area or the Facilities, construct,
install, operate, repair, remove, replace with similar Facilities, reconstruct, alter,
relocate, patrol, inspect, improve, enlarge, remove, and maintain the Facilities; (2)
have full right and authority to cut,fell,remove,trim,or otherwise control(including
without limitation by applying herbicides in accordance with applicable laws, rules
and regulations), all trees, brush, and other growth which might interfere with or
endanger the Facilities; (3)permit the joint use by others of rights of way and conduit
for similar purposes and for such other uses as may be required by law; and (4) have
reasonable access to, and ingress and egress for personnel, equipment and vehicles
over and across said Property in connection with PSCo's exercise of its rights
associated with the Facilities.
4. The right to prohibit the erection,placement or presence of buildings,structures,signs,
wells and other objects by Grantee, or by anyone claiming under Grantee,without the
prior written consent of Grantor, including trees, shrubs and fences that will or may
be an unreasonable interference with Grantor's Reserved Interests. Grantee, for itself
and its successors and assigns, agrees it will not perform any act within the Easement
Area that may unreasonably interfere with or endanger the Facilities and further agrees
that its use of the Property shall be consistent with the Reserved Interests. It is
understood and agreed that if Grantee requests the relocation or modification of any
of the Facilities located within the Easement Area, such relocation or modification
shall be at the expense of Grantee.
5. If access to and from PSCo's adjacent parcel is limited or prevented over the Easement
Area by any act or construction of Grantee, Grantee shall provide alternative access.
TD-1000
Confidential Document
Escrow No.: NCSC001927-SB
This form provides essential market information to the county assessor to ensure accurate, fair and uniform
assessments for all property. This document is not recorded, is kept confidential, and is not available for
public inspection.
This declaration must be completed and signed by either the grantor(seller) or grantee(buyer).
Questions 1, 2, 3, and 4 may be completed (prefilled) by a third party, such as a title company or closing agent,
familiar with details of the transaction. The signatory should confirm accuracy before signing.
This form is required when conveyance documents are presented for recording. If this form is not completed and
submitted, the county assessor may send notice, If the completed and signed form is not returned to the assessor
within thirty(30)days of notice, the assessor may impose a penalty of Twenty-Five And No/100 Dollars($25,00)or
0.025%(0.00025)of the sale price,whichever is greater.
Additional information as to the purpose, requirements, and level of confidentiality regarding this form are outlined
in Colorado Revised Statutes, sections 39-14-102, 39-5-121.5, and 39-13-102,
1, Physical Address and/or legal description of real property sold: Please do not use P.O. Box numbers.
Vacant Land, CO
2, Type of property purchased: 0 Single Family Residential 0 Townhome 0 Condominium
0 Multi-Unit Residential 0 Commercial 0 Industrial ❑ Agricultural 0 Mixed Use El Vacant Land
0 Other
3. 10/27/2025 07/14/2025
Date of closing: mm/dd/yyyy Date of contract: mm/dd/yyyy
4. $ 3,120,00 $
Total sale price: Include all real and personal property Contracted price(if different from final sale price)
5. List any personal property included in the transaction that materially impacts the total sale price.
Personal property may include, but is not limited to: machinery or equipment, vehicles, exceptional
appliances, electronic devices, furniture, or anything that would not typically transfer with the real property
(attach additional pages if necessary).
Description Approximate Value
NONE $ _
Personal Property Total: $
If no personal property is listed,the entire purchase price will be assumed to be for the real property.
6. Did the total sale price include a trade or exchange of additional real or personal property? m No 0 Yes
If Yes, approximate value of the goods or services as of the date of closing: $
If Yes, does this transaction involve a trade under IRS Code Section 1031?
7. Was One Hundred Percent(100%)interest in the real property purchased? 0 No 0 Yes
Mark"No"if only a partial interest is being purchased, If No, interest purchased
8. Is this a transaction between related parties or acquaintances? This includes persons connected by blood or
marriage,or business affiliates,or those acquainted prior to the transaction. 0 No 0 Yes
Real Property Transfer Declaration(TD-1000) Printed: 10.23,25 2 04;33 PM by 50
C001028,doc/Updated: 01,22,25 Page 1 CO—FCTV-030o0,990240•NCSC001927
9. Please mark type of sale: ❑Builder(new constructions) 0 Public(MLS or Broker Representation)
m Private(For Sale By Owner) 0 Other(describe)
10. Mark any of the following that apply to the condition of the improvements at the time of purchase,
❑ New ❑ Excellent ❑ Good ❑Average ❑ Fair 12 j.'oor 0 Salvage
11, Type of financing: (mark all that apply)
EI None(all cash or cash equivalent)
❑ New/Mortgage Lender(government-backed or conventional bank loan)
❑ New/Private Third Party(nonconventional lender, e.g., reiati've,friend, or acquaintance)
❑ Seller(buyer obtained a mortgage directly from the seller)
❑ Assumed (buyer assumed an existing mortgage)
0 Combination or Other: Please explain
12. Total amount financed$0.00
13. Terms:
❑ Variable;Starting interest rate _% ❑ Fixed; Interest rate
❑ Length of time years
❑ Balloon payment? 0 No ❑Yes If yes, amount$_ Due date:
14, Mark any that apply: ❑ Seller assisted down payments El Seller concessions ❑ Seller terms or financing
If marked, please specify terms:
15, Was an independent appraisal obtained in conjunction with this transaction? ❑ No ❑Yes
For properties OTHER THAN Residential (Residential is defined as: single family detached, townhomes,
apartments and condominiums)please complete questions 16-18 if applicable.
16, Did the purchase price include a franchise or license fee? RI No 0 Yes
If Yes,franchise or license fee value $
17. Did the purchase price involve an installment land contract? ICJ No 0 Yes
If Yes,date of contract
18. If this is vacant land,was an on-site inspection conducted by the buyer prior to the closing: No 0 Yes
Please include any additional information concerning the transaction and price paid that you feel is important:
Real Property Transfer Declaration(TD-1000) Printed: 10.23.25(d)04:33 PM by S6
COD1020.doc/Updated: 01.22.25 Page 2 CO—FCTV-03000,990240-NCSC001927
Weld County,Colorado, a body corporate and politic
under laws of the State of ColoradoBY:47 `� Gt�•'r Date
Name: err L
Title: \Ne I CoLiP'1 yt C04 I4,iCS.ipnr"r,C111;11.?
Buyer Mailing Address: Future correspondence (tax bills, property valuations, etc.) regarding this property should
be mailed to:
1150 O Street, PO BOX 758,Greeley, CO 80632 —. ...—
Address(mailing) City State Zip Code
i 70- 336 -7 2 3 _. GSc j � L . 9j 0v
Daytime Phone Email address
Contact information is kept confidential, for County Assessor and Treasurer use only, to contact buyer with
questions regarding this form, property valuation, or property tax information.
Real Property Transfer Declaration(TD-1000) Printed: 10.23.25 @ 04:33 PM by SE
C001028.doc/Updated: 01.22.25 Page 3 CO—FCTV-03000.990240-NCSC001927
DR 1083(10117113) 1" 1111 1 IU1I11 1 1 11
COLORADO DEPARTMENT OF REVENUE
Denver,CO B0261-0005 141083 19 9 9 9
wwe TaxCmccrado_care
Information with Respect to a Conveyance
of a Colorado Real Property Interest
1. Transferor's Last Name First Name Middle Initial
Weld County,Colorado, a body corporate and
politic under the'laws of the State of Colorado
Address City State Zip
1150 0 Street Greeley CO 80632
Spouse's Last Name(if applicable) First Name Middle Initial
Address City State Zip
2.Transferor is(check one): If other,please specify:
0 Individual 0 Estate 0 Corporation 0 Trust 0 Other(specify)
3.SSN Colorado Account Number 4. FEIN
5.Type of property sold 6.Date of closing(MMIoD/W)
7.Address or legal description of property sold City State Zip
8. Selling price of the property $3,120.00
9. Selling price of this transferor's interest $3,120.00
10. If Colorado tax was withheld,check this box 0
11. Amount of tax withheld $
12. If withholding is not made,give reason (check one):
a.Affirmation of Colorado residency signed 0
b.Affirmation of permanent place of business signed 0
c.Affirmation of principal residence signed ❑
d.Affirmation of partnership signed 0
e.Affirmation of no tax reasonably estimated to be due to no gain on sale signed 0
f. No net proceeds 0
13.Title Insurance Company Phone Number
Address City State Zip
File this form together with DR 1079, if applicable,within 30 days of the closing date with the
Colorado Department of Revenue
Denver,CO 80261-0005
1wilItII I1IIlUU1111
141083 29999
Affirmation of Colorado Residency
I (we) hereby affirm that I am (we are)the transferor(s)or the fiduciary of the transferor of the property described on this
DR 1083 and that as of the date of closing I am (we are)or the estate or the trust is a resident of the State of Colorado.
Signed under the penalty of perjury
Signature of transferor or fiduciary Date(MM/oDIYY)
Spouse's signature(if applicable) Date(MM/Dom)
Affirmation of Permanent Place of Business
I hereby affirm that the transferor of the property described on this DR 1083 is a corporation which maintains a
permanent place of business in Colorado.
Signed under the penalty of perju
Signature of corporate officer Date(MM/DDm)
Affirmation of Sale by Partnership
I hereby affirm that the transfer of property described on this DR 1083 was sold by an organization defined as a
partnership under section 761(a)of the Internal Revenue Code and required to file an annual federal partnership return
of income under section 6031(a)of the Internal Revenue Code.
Signed under the penalty of perjury.
Signature of general partner Date(MM/DD/YY)
Affirmation of Principal Residence
I hereby affirm that I am (we are)the transferor(s)of the property described on this DR 1083 and immediately prior to the
transfer it was my(our)principal residence which could qualify for the exclusion of gain provision of section 121 of the
Internal Revenue Code.
Signed under the penalty of perjury.
Signature of transferor Date(MM/oo ')
Spouse's signature if applicable Date(MMroom)
Affirmation of No Reasonably Estimated Tax to be Due
I hereby affirm that I am (we are)the transferor(s)or an officer of the corporate-transferor or a fiduciary of the estate
or trust-transferor of the property described on the front side of this form, and I (we)further affirm that there will be no
Colorado income tax reasonably estimated to be due on the part of the transferor(s)as a result of any gain realized on
the transfer.
Please understand before you sign this affirmation that nonresidents of Colorado are subject to Colorado tax
on gains from the sale of Colorado real estate to the extent such gains are included in federal taxable income.
Signed under the penalty of perjury.
Signature of transferor,officer,or fiduciary Date(MM/oom)
Spouses signature if applicable Date(MM/cDm)
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