Corporation {L-C}

Page 1 of 2 Form L-C (0/201) CORPORATION L-C (0/201) This Corporation form should be completed for original applications or for changes of officers, directors, stockholders, trustees, and beneficiaries holding ownership in this business. This form is included in the Business Packet (L-B) for new applicants. License/Permit holders reporting changes use Business Packet for Reporting Changes (L-BRC). For more information contact your local TABC office or visit us at: www.tabc .texas.gov ENTITY INFORMATION 1. Fed eral Employer Identification Number (FEIN) 2. Business Entity Name 3. Filing N umber 4 . Date Filed (mm/dd/yyyy) State Class and Number of Shares Issued CORPORATE OWNERSHIP INFORMATION Officer Director Stockholder Trustee Beneficiary SSN Out of Country Issuing State/DL No. Date of Birth (mm/dd/yyyy) Class & No. of Share s Last Name First Name MI Title Officer Director Stockholder Truste e Beneficiary SSN Out of Country Issuing State/DL No. Date of Birth (mm/dd/yyyy) Class & No. of Shares Last Name First Name MI Title Officer Director Stockholder Truste e Beneficiary SSN Out of Country Issuing State/DL No. Date of Birth (mm/dd/yyyy) Class & No. of Shares Last Name First Name MI Title Officer Director Stockholder Trustee Beneficiary SSN Out of Country Issuing State/DL No. Date of Birth (mm/dd/yyyy) Class & No. of Shares Last Name First Name MI Title American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Form L-C (0/201) CORPORATE OWNERSHIP INFORMATION CONTINUED Officer Director S tockholder Trustee Beneficiary SSN Out of Country Issuing State/DL No. Date of Birth (mm/dd/yyyy) Class & No. of Shares Last Name First Name MI Title Officer Director St ockholder Trustee Beneficiary SSN Out of Country Issuing State/DL No. Date of Birth (mm/dd/yyyy) Class & No. of Shares Last Name First Name MI Title Officer Director Sto ckholder Trustee Beneficiary SSN Out of Country Issuing State/DL No. Date of Birth (mm/dd/yyyy) Class & No. of Shares Last Name First Name MI Title Officer Director Stoc kholder Trustee Beneficiary SSN Out of Country Issuing State/DL No. Date of Birth (mm/dd/yyyy) Class & No. of Shares Last Name First Name MI Title Officer Director Stock holder Trustee Beneficiary SSN Out of Country Issuing State/DL No. Date of Birth (mm/dd/yyyy) Class & No. of Shares Last Name First Name MI Title Officer Director Stockh older Trus t e e Beneficiary SSN Out of Country Issuing State/DL No. Date of Birth (mm/dd/yyyy) Class & No. of Shares Last Name First Name MI Title Officer Director Stockho lder Trustee Beneficiary SSN Out of Country Issuing State/DL No. Date of Birth (mm/dd/yyyy) Class & No. of Shares Last Name First Name MI Title IF YOU NEED MORE SPA CE USE ADDITIONAL C OPIES OF THIS PAGE American LegalNet, Inc. www.FormsWorkFlow.com