Limited Liability Company Disclosure Form {DLC 4032}

NameSocial Security No.Residence AddressTax Identification No.ZipcodeBirthdate List the managing members and all persons with a 5% or more membership or voting interest in the LLC. Telephone No. SECTION B. List the top five (5) officers of the Limited Liability Company. NAME OF OFFICER: (if an office is NOT held, please write "ONEN")SOCIAL SECURITY NUMBERDATE OF BIRTH CEO PresidentVice-PresidentSecretaryTreasurer/CFO LIQ-18-0016 - DLC 4032 /s/ //www.com.ohio.gov/documents/liqrFingerPrint.pdf.By signing below, I certify that I have authority to execute this document and the information provided is true, correct and complete to thebest of my knowledge and belief.(Position) (Date)(eSignature - Electronic Signature)(Address)(City)(State)(Zip Code)(Telephone Number) CityState Social Security No.Tax Identification No.BirthdateTelephone No.NameResidence AddressZipcodeCityState 614 | 644 2360 Fax 614 | 644 3166 TTY/TDD 800 | 750 0750 www.com.ohio.govAn Equal Opportunity Employer and Service Provider6606 Tussing RoadPO Box 4005Reynoldsburg, OH 43068-9005 U.S.A.Rev. 5/13/2019 American LegalNet, Inc. www.FormsWorkFlow.com The Background check process can be found at https://www.com.ohio.gov/documents/liqrFingerPrint.pdf. List the managing members and all persons with a 5% or more membership or voting interest in the LLC.If none, please indicate by writing "NONE":Individuals listed below must have a background check performed by BCI, and submit a Personal History Background Form. 5)6)9) Social Security No.Tax Identification No.BirthdateTelephone No.Social Security No.Tax Identification No.BirthdateTelephone No.Social Security No.Tax Identification No.BirthdateTelephone No.Social Security No.Tax Identification No.BirthdateTelephone No.Social Security No.Tax Identification No.BirthdateTelephone No.Social Security No.Tax Identification No.BirthdateTelephone No.Social Security No.Tax Identification No.BirthdateTelephone No.NameResidence AddressZipcodeCityStateNameResidence AddressZipcodeCityStateNameResidence AddressZipcodeCityStateNameResidence AddressZipcodeCityStateNameResidence AddressZipcodeCityStateNameResidence AddressZipcodeCityStateNameResidence AddressZipcodeCityStateLIQ-18-0016DLC 4032 American LegalNet, Inc. www.FormsWorkFlow.com