Ownership Disclosure Certification

I certify that the list below contains the names and home addresses of all owners holding 10% or more of the issued and outstanding stock of the undersigned.

Check the box that represents the type of business entity:

Partnership

Corporation

Sole Proprietorship

Subchapter S Corporation

Limited Partnership

Limited Liability Corporation

Limited Liability Partnership

Name of Stock or Shareholder	Home Address

Signature and Attestation:

The undersigned is fully aware that if I have misrepresented in whole or part this affirmation and certification, I and/or the business entity, will be liable for any penalty permitted under law.

Name of Business Entity:

Signature of Affiant:

Title:

Printed Name of Affiant:

Date:

Subscribed and sworn before me this day of

, 2 .

(Witnessed or attested by)

My Commission expires:

(Seal)