Disclosure Of Ownership (Corp) {320}

Secretary of State DISCLOSURE OF OWNERSHIP(R.S. 12:1-1622, 12:205 E and 12:304 A (11)) Return to: Commercial Division Enclose $20 filing fee Make remittance payable to Secretary of State Do Not Send Cash P.O. Box 94125 Baton Rouge, LA 70804-9125 State of Parish/County of BEFORE ME, the undersigned Notary in and for the parish/county herein above shown, personally came and appeared the undersigned who, after being duly sworn, did depose and say that: Corporation Name is contracting with the state and listed below are the names and addresses of all persons or corporate entities who hold ownership interest of five percent or more in the corporation or who hold by proxy the voting power of five percent or more in the corporation and, if anyone is holding stock in his own name that actually belongs to another, the name of the person for whom held, including stock held pursuant to a counter letter.1.Persons or corporate entities owning 5% or more:NameAddressNameAddressNameAddress2.Persons or corporate entities who hold by proxy the voting power of 5% or more:NameAddressNameAddressNameAddress3.Stock held for others and for whom held: Name Address For Whom Held Address Name Address For Whom Held Address Name Address For Whom Held Address Sworn to and subscribed before me, the undersigned Notary Public, on this date: Corporation Representative Notary Signature, Printed Name and Notary /Bar Roll # SS320 Rev. 0 (See instructions on back) INSTRUCTIONS This form is be used when an existing corporation intends to contract with the state This requirement does not apply to non profit corporations organized on a 223non stock224 basis, any agreement entered between the state and a corporation for electric or gas service, publicly traded corporations, or state chartered banks. You will receive a copy marked 223received and filed224 by the secretary of state. You may furnish a photostatic copy of the 223filed224 form to the appropriate state agency. www.FormsWorkflow.com