Entity Structure Supplemental Information Form {ABL-919}

1350 STATE OF SOUTH CAROLINA DEPARTMENT OF REVENUE LIMITED LIABILITY CORPORATION (LLC) SUPPLEMENTAL INFORMATION FORM ABL-919 (Rev. 2/29/12) 4378 Check all boxes that apply and provide the requested information as requested herein: Name of this LLC applying for permit and/or license: This LLC is managed by its Members: This LLC has an Operating Agreement, a copy of which is attached hereto, and each Member is identified in the agreement. This LLC does not have an Operating Agreement. Listed below is the name of every Member that has an ownership interest in the LLC. This LLC is managed by its Managers: This LLC has an Operating Agreement, a copy of which is attached hereto, and each Manager is identified in the agreement. This LLC does not have an Operating Agreement. Listed below is the name of every Manager of the LLC. Name Title Percentage of Ownership I, , upon being first duly sworn, upon penalty of perjury, do hereby acknowledge and affirm that the foregoing is true and correct and that all information requested has been fully provided. (L.S.) Taxpayer's Signature SWORN to and subscribed before me this day of Notary Public for My Commission Expires: Notary (L.S.) Notary (printed name) , year of 43781012 American LegalNet, Inc. www.FormsWorkFlow.com