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Limited Liability Company Disclosure Form DLC 4032 - Ohio
| Limited Liability Company Disclosure Form Form. This is a Ohio form and can be used in Division Of Liquor Control Department Of Commerce Statewide . |
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OHIO DEPARTMENT OF COMMERCE - DIVISION OF LIQUOR CONTROL 6606 Tussing Road, P.O. Box 4005, Reynoldsburg, Ohio 43068-9005 FOR OFFICE USE ONLY NEW PERMIT # TRANSFER Telephone: (614) 644-2431 - http://www.com.state.oh.us LIMITED LIABILITY COMPANY DISCLOSURE FORM Section A (This form must accompany all applications of an LLC business entity) DBA Name City, State Tax Identification No. (TIN) Name of Limited Liability Company Permit Premises Address Township, if in Unincorporated Area Zip Code Limited Liability Company ("LLC") - Chapter 1705 Ohio Revised Code. Indicate below the managing members, LLC Officers, and all persons with a 5% or greater membership or voting interest, and attach a copy of the Articles of Organization filed with the Ohio Secretary of State. Please be advised that any social security numbers provided to the Division of Liquor Control in this application may be released to the Ohio Department of Public Safety, the Ohio Department of Taxation, the Ohio Attorney General, or to any other state or local law enforcement agency if the agency requests the social security number to conduct an investigation, implement an enforcement action, or collect taxes. SECTION B. List the top five (5) officers of the captioned business. If an office is NOT held, please indicate by writing NONE. EACH OFFICER LISTED BELOW MUST SUBMIT A CIVILIAN IDENTIFICATION CARD & PERSONAL HISTORY BACKGROUND FORM NAME OF OFFICER SOCIAL SECURITY NUMBER DATE OF BIRTH 1) CEO 2) President 3) Vice-President 4) Secretary 5) Treasurer SECTION C. List the managing members and all persons with a 5% or greater membership or voting interest in the LLC. ALL INDIVIDUALS LISTED BELOW MUST SUBMIT A CIVILIAN IDENTIFICATION CARD & PERSONAL HISTORY BACKGROUND FORM 1) Name Residence Address City and State Telephone No. 2) Name Residence Address City and State Telephone No. Social Security No. (if individual) Tax Identification No. (if applicable) Zip Code Date of Birth Social Security No. (if individual) Managing Member Tax Identification No. (if applicable) 5% or greater voting interest Zip Code 5% or greater membership interest Date of Birth (PLEASE SEE REVERSE SIDE SHOULD YOU NEED ADDITIONAL SPACE ) Managing Member 5% or greater voting interest 5% or greater membership interest STATE OF OHIO, ___________________________________________ COUNTYss, I, ____________________________________________________being first duly sworn, according to law, deposes and says that he/she is (Title) _____________________ of the ______________________________________________, a business duly authorized by law to do business in the State of Ohio, and that the statements made in the forgoing affidavit are true. (Signature) ___________________________________________________ (Print Name and Title) _______________________________________________________ Sworn to and subscribed in my presence this __________________ day of _____________________________________________________, _______________________ ___________________________________________________________ (Notary Public) (Notary Expiration) DLC 4032 EOE/ADA SERVICE PROVIDER FOR TTY USERS DIAL 1-800-750-0750 REV. 8-30-04 American LegalNet, Inc. www.FormsWorkflow.com Page 2 DLC4032 (LIMITED LIABILITY COMPANY DISCLOSURE FORM) SECTION C (CONTINUED) List the managing members and all persons with a 5% or greater membership or voting interest in the LLC. ALL INDIVIDUALS LISTED BELOW MUST SUBMIT A CIVILIAN IDENTIFICATION CARD & PERSONAL HISTORY BACKGROUND FORM 3) Name Residence Address City and State Telephone No. 4) Name Residence Address City and State Telephone No. 5) Name Residence Address City and State Telephone No. 6) Name Residence Address City and State Telephone No. 7) Name Residence Address City and State Telephone No. 8) Name Residence Address City and State Telephone No. 9) Name Residence Address City and State Telephone No. Social Security No. (if individual) Managing Member Tax Identification No. (if applicable) 5% or greater voting interest Zip Code 5% or greater membership interest Date of Birth Social Security No. (if individual) Managing Member Tax Identification No. (if applicable) 5% or greater voting interest Zip Code 5% or greater membership interest Date of Birth Social Security No. (if individual) Managing Member Tax Identification No. (if applicable) 5% or greater voting interest Zip Code 5% or greater membership interest Date of Birth Social Security No. (if individual) Tax Identification No. (if applicable) Zip Code Date of Birth Social Security No. (if individual) Managing Member Tax Identification No. (if applicable) 5% or greater voting interest Zip Code 5% or greater membership interest Date of Birth Social Security No. (if individual) Tax Identification No. (if applicable) Zip Code Date of Birth Social Security No. (if individual) Tax Identification No. (if applicable) Zip Code Date of Birth Managing Member 5% or greater voting interest 5% or greater membership interest Managing Member 5% or greater voting interest 5% or greater membership interest Managing Member 5% or greater voting interest 5% or greater membership interest American LegalNet, Inc. www.FormsWorkflow.com
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