Fill and Sign the Certificate Notice Form

District Court, Water Division ___________________, Colorado Court Address : ________________________________________________________ CONCERNING THE APPLICATION FOR WATER RIGHTS OF Applicant: In the ____________________________River or its Tributaries In ________________________________________ COUNTY COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E-mail: FAX Number: Atty. Reg. #: Case Number: Division: Courtroom: Certificate of Notice I, (insert name) hereby certify that I have provided a copy of the Application filed on (date) with the Court to the following owner(s) of the land upon which any new diversion or storage structure or modification to any existing diversion or storage structure or existing storage pool is or will be constructed or upon which water is or will be stored: 1. 2. 3. The application was provided to the landowner(s) by Certified or Registered mail, return receipt requested, within 14 days after the application was filed with the Court. Date: Signature/Title JDF 290W R7/13 CERTIFICATE OF NOTICE