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L-BRCI (4/2020)
Business Packet for Reporting Changes The Business Packet for
Reporting Changes (L-BRC) must be completed if there has been any
change within your current business structure or applying for a
change of class. This packet includes the following forms:
• L-C (Corporation, Trust, City, County or University)• L-LLC
(Limited Liability Company)• L-P (Partnership)• L-PHS (Personal
History Sheet) – For any new officer, director, manager or
majority
stockholder/member/partner to your entity. Note: This form
(L-PHS) is not required forholders of an S, U, BS and DS.
Submit your completed packet to your local TABC office. To find
your local office access our website at
www.tabc.texas.gov/contact_us/local_field_office.asp
If you are a holder of an S, U, BS or DS, submit your
application directly to TABC, PO Box 13127 Austin TX 78711-3127.
For questions and/or assistance contact [email protected] or
by phone at 512-206-3360.
Type of Change:
• Officers, Manager, Director, Stockholder, Member or
Trustee/Beneficiary: Depending on yourbusiness type, complete
any/all of the following: L-BRC, L-C, L-LLC and/or L-P. A
completebusiness structure must be disclosed on these forms.
Personal history sheets (L-PHS) must becompleted for any new
officer, director, manager or majority stockholder/member/partner
to yourentity.
• Change of Business Entity: Complete the entire Business Packet
for Reporting Changes (L-BRC,L-C, L-LLC and/or L-P) for each
location affected by the change. TABC requires 10 days priornotice
of the change. A Personal History Sheet(s) (L-PHS) for each new
individual to your entity anda $100.00 fee will be required for
each location. Review Section 11.12, of the Texas AlcoholicBeverage
Code, for qualification and additional requirements. Your current
License/Permit will needto be submitted with your application.
• Merger: Complete entire Business Packet for Reporting Changes
(L-BRC, L-C, L-LLC and/or L-P),The merger must be reported within
10 days of the occurrence, a $100.00 fee per each location, andan
affidavit including all tradenames and locations with
license/permit numbers affected must beincluded. Complete Personal
History Sheets (L-PHS) for new individuals to your entity. Your
currentLicense/Permit will need to be submitted with your
application.
• Conversion: Complete the entire Business Packet for Reporting
Changes (L-BRC, L-C, L-LLCand/or L-P), attach the certificate of
conversion, and an affidavit including all tradenames andlocations
with license/permit numbers. Complete Personal History Sheets
(L-PHS) for newindividuals to your entity. Your current
License/Permit will need to be submitted with your application.
• Change of Class (for change of class only): Complete form
(L-BRC) pages 1 and 2 (that apply toyour change) and submit any
fees required. Your current License/Permit will need to be
submittedwith your application.
• Consolidation (Package Store Only): Complete the entire
Business Packet for Reporting Changes(L-BRC, L-C, LLC, and/or L-P),
attach the letter of intent to consolidate (consanguinity letter)
and aPersonal History Sheet (L-PHS) must be completed for new
individuals to your entity.
http://www.tabc.texas.gov/contact_us/local_field_office.aspmailto:[email protected]
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Page 1 of 2 Form L-BRC (4/2020)
BUSINESS PACKET for REPORTING CHANGES
L-BRC(4/2020)
You must complete the entire Business Packet for Reporting
Changes according to your changes as outlined on the instruction
sheet (L-BRCI). Select appropriate entity pages. Personal history
sheets (L-PHS) must be completed for any new officer, director,
manager or majority stockholder/member/partner. All statutory
references mentioned in this application refer to and can be found
in the Texas Alcoholic Beverage Code located on our website.
www.tabc.texas.gov/laws/code_and_rules.asp
INDICATE ALL CHANGE(S) YOU ARE REPORTING WITH THIS APPLICATION
1. Current License/Permit No. 2. Contact Phone Number 3. Email
Address
4. Type of ChangeOfficer, Manager, Director, Stockholder, Member
Merger Partner (limited or general) Conversion Trustee/Beneficiary
Consolidation (Package Store Only) Change of Business Entity
Other
5. Effective Date of above change (MM/DD/YYYY)
6. Are you applying for a change of class? Yes NoIf “YES,”
indicate type of change:FROM Wine and Beer Retailer’s Permit (BG)
TO Wine and Beer Retailer’s Off-Premise Permit (BQ) FROM Beer
Retailer’s On-Premise License (BE) TO Beer Retailer’s Off-Premise
License (BF)
OWNER INFORMATION 7. Owner of Business on Current License/Permit
8. Federal Employer Identification No. (FEIN)
OWNER INFORMATION (ONLY FOR CHANGE OF BUSINESS ENTITY, MERGER,
AND CONVERSION) 9. Type of Owner
Individual Partnership City/County/University Other Corporation
Limited Partnership Joint Venture Limited Liability Company Limited
Liability Partnership Trust
BUSINESS INFORMATION 10. If any person listed in this Business
Packet, or his or her spouse, has been finally convicted or
any felony offense prostitution bookmaking gambling or gaming
bootlegging vagrancy offense involving moral turpitude any offense
involving dangerous drugs, synthetic cannabinoids or controlled
substances as defined in Texas Controlled Substances Act any
offense involving firearms or a deadly weapon more than three
violations of the Texas Alcoholic Beverage Code relating to minors
violations of the Texas Alcoholic Beverage Code resulting in a
criminal fine of $500 violations of an individual’s civil rights or
discrimination against an individual on the basis or race, color,
creed or national origin
Yes NoHas it been five years since the termination of a
sentence, parole or probation served for any offenses indicated
above? If it has not been five years since the termination of a
sentence, parole or probation served, attach an explanation.
11. Has any person listed in this Business Packet, or his or her
spouse, had a cancellation of a license or permitin the past five
years? Yes No
If “YES,” attach an explanation.
N/A
received deferred adjudication for any of the offenses below,
indicate by checking all that apply:
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Page 2 of 2 Form L-BRC (4/2020)
The applicant, license/permit holder, agent, servant or employee
may not directly or indirectly have any overlapping ownerships or
other prohibited relationships (including unfair competition and
unlawful trade practices) between those engaged in the alcoholic
beverage industry at different levels, that is, between a
manufacturer and a wholesaler or retailer, or between a wholesaler
and a retailer, as the words "wholesaler," "retailer," and
"manufacturer" are ordinarily used and understood, regardless of
the specific names given a license\permit. Reference Chapter 102 et
seq.
12. Is any person, involved in this application, in violation of
the above requirements? Yes NoIf “YES,” attach an explanation.
COMPTROLLER OF PUBLIC ACCOUNTS CERTIFICATE (FOR CHANGE OF ENTITY
ONLY)
This is to certify on this day of , 20 , the applicant holds or
has applied for and satisfies all legal requirements for the
issuance of a Sales Tax Permit under the Limited Sales, Excise and
Use Tax Act or the applicant as of this date is not required to
hold a Sales Tax Permit.
Sales Tax Permit Number Outlet Number
Print Name of Comptroller Employee
Print Title of Comptroller Employee
SIGN HERE FIELD OFFICE
S E A L
WARNING AND SIGNATURE
If Applicant Is/Must Sign Individual/Individual Owner
Corporation/Officer Partnership/Partner Limited Liability Company/
Officer or Manager Limited Partnership/General Partner
EACH LICENSEE OR PERMITTEE SHALL HAVE EXCLUSIVE OCCUPANCY AND
CONTROL OF THE ENTIRE LICENSED LOCATION WITH RESPECT TO SALE OF
ALCOHOLIC BEVERAGES. ANY ARRANGEMENT THAT SURRENDERS SUCH CONTROL
OF THE EMPLOYEES, PREMISES OR BUSINESS, INCLUDING PROFITS AND
LOSSES, TO PERSONS OTHER THAN THE LICENSEE OR PERMITTEE IS
UNLAWFUL.
WARNING: Section 101.69 of the Texas Alcoholic Beverage Code
states: “…a person who makes a falsestatement or false
representation in an application for a permit or license or in a
statement, report, or other instrument to be filed with the
Commission and required to be sworn commits an offense punishable
by imprisonment in the Texas Department of Criminal Justice for not
less than 2 nor more than 10 years.”
BY SIGNING YOU ARE SWEARING TO ALL INFORMATION AND ATTACHMENTS
TO THIS PACKET.
PRINT NAME
SIGN HERE
TITLE
Before me, the undersigned authority, on this day of , 20 , the
person whose name is signed to the foregoing application personally
appeared and, duly sworn by me, states under oath that he or she
has read the said application and that all the facts therein set
forth are true and correct. SIGN HERE
NOTARY PUBLIC
S E A L
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Page 1 of 2 Form L-C (4/2020)
CORPORATION
L-C (4/2020)
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. Federal Employer Identification Number
(FEIN)
2. Business Entity Name
3. Filing Number
4. Date Filed (mm/dd/yyyy) State Class and Number of Shares
Issued
CORPORATE OWNERSHIP INFORMATION Officer Director Stockholder
Trustee Beneficiary (Mark All That Apply)
Last Name First Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Specify Class
& No. of Shares
Officer Director Stockholder Trustee Beneficiary (Mark All That
Apply) Last Name First Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Specify Class
& No. of Shares
Officer Director Stockholder Trustee Beneficiary (Mark All That
Apply) Last Name First Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Specify Class
& No. of Shares
Officer Director Stockholder Trustee Beneficiary (Mark All That
Apply) Last Name First Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Specify Class
& No. of Shares
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Page 2 of 2 Form L-C (4/2020)
CORPORATE OWNERSHIP INFORMATION CONTINUED Officer Director
Stockholder Trustee Beneficiary (Mark All That Apply)
Last Name First Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Specify Class
& No. of Shares
Officer Director Stockholder Trustee Beneficiary (Mark All That
Apply) Last Name First Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Specify Class
& No. of Shares
Officer Director Stockholder Trustee Beneficiary (Mark All That
Apply) Last Name First Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Specify Class
& No. of Shares
Officer Director Stockholder Trustee Beneficiary (Mark All That
Apply) Last Name First Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Specify Class
& No. of Shares
Officer Director Stockholder Trustee Beneficiary (Mark All That
Apply) Last Name First Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Specify Class
& No. of Shares
Officer Director Stockholder Trustee Beneficiary (Mark All That
Apply) Last Name First Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Specify Class
& No. of Shares
Officer Director Stockholder Trustee Beneficiary (Mark All That
Apply) Last Name First Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Specify Class
& No. of Shares
Officer Director Stockholder Trustee Beneficiary (Mark All That
Apply) Last Name First Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Specify Class
& No. of Shares
IF YOU NEED MORE SPACE USE ADDITIONAL COPIES OF THIS PAGE
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Page 1 of 2 Form L-LLC (4/2020)
LIMITED LIABILITY COMPANY
L-LLC(4/2020)
This Limited Liability Company form should be completed for
original applications or for changes of officers, managers, and
members holding ownership in this business. This form is included
in the Business Packet (L-B) for new applicants. License/Permit
holders reporting changes use the Business Packet for Reporting
Changes (L-BRC). For individuals outside the United States, not
holding a social security number check the "Out of Country"
box.
For more information contact your local TABC office or visit us
at: www.tabc.texas.gov ENTITY INFORMATION
1. Federal Employer Identification Number (FEIN)
2. Business Entity Name
3. Filing Number 4. Member Managed or Manager Managed
Member Managed Manager Managed 5. Date Filed (mm/dd/yyyy) State
Class and Number of Memberships or Units Issued
LIMITED LIABILITY COMPANY OWNERSHIP INFORMATION Officer Manager
Member (Mark All That Apply)
Last Name First Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percentage
Membership or Units Held
Officer Manager Member (Mark All That Apply) Last Name First
Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percentage
Membership or Units Held
Officer Manager Member (Mark All That Apply) Last Name First
Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percentage
Membership or Units Held
Officer Manager Member (Mark All That Apply) Last Name First
Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percentage
Membership or Units Held
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Page 2 of 2 Form L-LLC (4/2020)
LIMITED LIABILITY COMPANY OWNERSHIP INFORMATION CONTINUED
Officer Manager Member (Mark All That Apply)
Last Name First Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percentage
Membership or Units Held
Officer Manager Member (Mark All That Apply) Last Name First
Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percentage
Membership or Units Held
Officer Manager Member (Mark All That Apply) Last Name First
Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percentage
Membership or Units Held
Officer Manager Member (Mark All That Apply) Last Name First
Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percentage
Membership or Units Held
Officer Manager Member (Mark All That Apply) Last Name First
Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percentage
Membership or Units Held
Officer Manager Member (Mark All That Apply) Last Name First
Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percentage
Membership or Units Held
Officer Manager Member (Mark All That Apply) Last Name First
Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percentage
Membership or Units Held
Officer Manager Member (Mark All That Apply) Last Name First
Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percentage
Membership or Units Held
IF YOU NEED MORE SPACE USE ADDITIONAL COPIES OF THIS PAGE
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Page 1 of 2 Form L-P (4/2020)
PARTNERSHIP
L-P (04/2020)
This Partnership form should be completed for original
applications or for changes of partnerships, limited partnerships,
limited liability partnerships, and joint ventures 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. Federal Employer Identification Number
(FEIN).
2. Business Entity Name
3. Filing Number
4. Date Filed (mm/dd/yyyy) State
PARTNERSHIP INFORMATION General Partner Limited Partner
Last Name First Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percent of
Interest
General Partner Limited Partner Last Name First Name MI
Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percent of
Interest
General Partner Limited Partner Last Name First Name MI
Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percent of
Interest
General Partner Limited Partner Last Name First Name MI
Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percent of
Interest
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Page 2 of 2 Form L-P (4/2020)
PARTNERSHIP INFORMATION CONTINUED General Partner Limited
Partner
Last Name First Name MI Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percent of
Interest
General Partner Limited Partner Last Name First Name MI
Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percent of
Interest
General Partner Limited Partner Last Name First Name MI
Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percent of
Interest
General Partner Limited Partner Last Name First Name MI
Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percent of
Interest
General Partner Limited Partner Last Name First Name MI
Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percent of
Interest
General Partner Limited Partner Last Name First Name MI
Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percent of
Interest
General Partner Limited Partner Last Name First Name MI
Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percent of
Interest
General Partner Limited Partner Last Name First Name MI
Title
SSN Out of Country Date of Birth (mm/dd/yyyy) Percent of
Interest
IF YOU NEED MORE SPACE USE ADDITIONAL COPIES OF THIS PAGE
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Page 1 of 2 Form L-PHS (4/2020)
PERSONAL HISTORY SHEET L- PHS
(4/2020)Every officer and majority owner must complete a
Personal History Statement. Answer all questions. Any false
statement will disqualify you and subject you to prosecution under
section 101.69 of the Texas Alcoholic Beverage Code and other
criminal statutes.
OWNER/APPLICANT1. Trade Name (Name of restaurant, bar, etc.)
2. Location Address:3. Marital Status: Single Married Divorced
Widowed
Social Security Number Issuing State/ Driver’s License Number
Date of Birth (mm/dd/yyyy)
4. Full Legal Name (Last, First, Middle)
Place of Birth (City, State, Country)
Email Address
SPOUSE
Social Security Number Issuing State/ Driver License Number Date
of Birth (mm/dd/yyyy)
5. Full Legal Name (Last, First, Middle)
Place of Birth (City, State, Country)
OTHER RESIDENT6. Do you live with anyone over the age of 18,
other than your spouse? YES NO
If “YES” please provide their information below: (If additional
space is needed, please attach a page with information.)
Social Security Number Issuing State/ Driver License No. Date of
Birth (mm/dd/yyyy) Relationship
Full legal name (Last, First, Middle)
RESIDENTIAL ADDRESSES 7. List residential addresses for the past
five (5) years starting with current address.
If you have not lived in Texas for the previous 12 months, you
are required to provide TABC with an official copy of your
criminalbackground check from the FBI or state police of any state
where you lived in the previous five years.(If additional space is
needed, please attach a list with the following information.)
Number and Street City, State, ZIP From (mm/yyyy) To (mm/yyyy)
PRESENT
8. Business Phone No. Residential Phone No. Mobile Phone No.
RESIDENT STATUS 9A. Are you a U.S. citizen? YES NO
B. If “YES” answer the following: Native Born Naturalized. If
“Naturalized,” Provide the “A” Number ____________
C. If “NO” What is your legal status in the United States?
Explain below, or attach a page with information.
D. Provide all documents such as Visa, Resident Alien,
Employment Authorization Documents, etc.
TA
BC
US
E
ON
LY
APPLICANT YES NO SPOUSE (BE/BG ONLY) YES NO OTHER YES NO CH -
Date Entered
/ / Supervisor’s Signature Destroy Date
/ /
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Page 2 of 2 Form L-PHS (4/2020)
EMPLOYMENT HISTORY 10. List employment for the past five (5)
years beginning with your current employer. If self-employed or
retired, include the name of your
company or company from which you retired, type of business
owned or the position held prior to retirement. Include periods
ofunemployment. All periods of time must be accounted for during
the past five years. (If additional space is needed, attach a
separatesheet.)
Name of Employer/Company Address (Street, City, State, ZIP)
Position Held/Business Type From (mm/yyyy)
To (mm/yyyy)
PRESENT
INDIVIDUAL FINANCIAL INFORMATION 11. List the total amount of
your personal investment in this location. Provide investment
details including notes, loans, gifts,
cash, services or equipment, and operating capital. Account for
the original source of all investments (how acquired).Enter total
dollar amount on the line of the amount invested column.(If
additional space is needed, attach a separate sheet.)
NOTE: If investment is in the form of a loan or gift, attach
name of lender or financial institution, address, terms andsecurity
and loan/gift documents. If from an individual, attach personal
information for all individuals including:name, social security and
driver license numbers, date of birth, race, sex, etc.
Amount Invested Original Source of Investment (loans, previous
employment, etc). $
$
$
$
$
$
$ TOTAL AMOUNT OF PERSONAL INVESTMENT SIGN AND NOTARIZE
APPLICATION
WARNING: Section 101.69 of the Texas Alcoholic Beverage Code
states: “…a person who makes a false statement or
falserepresentation in an application for a permit or license or in
a statement, report, or other instrument to be filed with the
Commission and required to be sworn commits an offense punishable
by imprisonment in the Texas Department of Criminal Justice for not
less than 2 nor more than 10 years.”
I, under penalty of law, hereby swear that I have read all the
information provided in this document and any attachments and the
information is true and correct. I also understand any false
statement or representation in this application can result in my
application being denied and/or criminal charges filed against me.
I also authorize the Texas Alcoholic Beverage Commission to use all
legal means to verify the information provided.
PRINT NAME:
AUTHORIZED SIGNATURE:
BEFORE ME, the undersigned authority, on this day of , 20 the
person whose name is signed to the foregoing document personally
appeared and duly sworn by me, each states under oath that he or
she has read the said document and that all facts therein set forth
are true and correct.
SIGN HERE:
(S E A L) Notary Public
Business Packet for Reporting Change 02-05-18Business Packet for
Reporting Change 02-05-18Business Packet for Reporting
Changes11-17L-BRCI 06-22-17Business Packet for Reporting
Changes
L-BRC 08-31-17BUSINESS PACKET for REPORTING CHANGESINDICATE ALL
CHANGE(S) YOU ARE REPORTING WITH THIS APPLICATIONOWNER
INFORMATIONBUSINESS INFORMATIONCOMPTROLLER OF PUBLIC ACCOUNTS
CERTIFICATE (FOR CHANGE OF ENTITY ONLY)SIGN
L-C 01-24-18CORPORATIONENTITY INFORMATIONCORPORATE OWNERSHIP
INFORMATIONCORPORATE OWNERSHIP INFORMATION CONTINUED
L-LLC 01-26-18LIMITED LIABILITY COMPANYENTITY INFORMATIONLIMITED
LIABILITY COMPANY OWNERSHIP INFORMATIONLIMITED LIABILITY COMPANY
OWNERSHIP INFORMATION CONTINUED
L-P 01-24-17PARTNERSHIPENTITY INFORMATIONPARTNERSHIP
INFORMATIONPARTNERSHIP INFORMATION CONTINUED
L-PHS 10-03-2018v2
L-BRC Lic: Permit #:
L-BRC Contact Phone: L-BRC Email: L-BRC Officer, Manger:
OffL-BRC Merger: OffL-BRC Partner limited or general: OffL-BRC
Conversion: OffL-BRC TrusteeBeneficiary: OffL-BRC Consolidation
Package Store Only: OffL-BRC Change of Business Entity: OffL-BRC
Other: OffL-BRC Other Text: L-BRC Effective Date: L-BRC Change of
Class: OffL-BRC BG to BQ: OffL-BRC BE to BF: OffL-BRC Owner of
Business on Current LicensePermit: L-BRC Federal Employer
Identification No FEIN: L-BRC Individual: OffL-BRC Partnership:
OffL-BRC CityCountyUniversity: OffL-BRC Other_2: OffL-BRC
Corporation: OffL-BRC Limited Partnership: OffL-BRC Joint Venture:
OffL-BRC Limited Liability Company: OffL-BRC Limited Liability
Partnership: OffL-BRC Trust: OffL-BRC Conviction: OffL-BRC Felony:
OffL-BRC prostitution: OffL-BRC bookmaking: OffL-BRC gambling:
OffL-BRC bootlegging: OffL-BRC turpitude: OffL-BRC drugs: OffL-BRC
firearms: OffL-BRC Minors: OffL-BRC TABC criminal: OffL-BRC civil
rights: OffL-BRC 5 Years: OffL-BRC Cancelation: OffL-BRC Violation:
OffL-BRC Sales Tax Permit Number: L-BRC Print NAME: L-BRC TITLE:
L-C FEIN: L-C Business Entity Name: L-C Filing Number: L-C Date
Filed: L-C Filing State: L-C Officer: OffL-C Director: OffL-C
Stockholder: OffL-C Trustee: OffL-C Beneficiary: OffL-C Last Name:
L-C First Name: L-C MI: L-C Title: L-C OOC 1: OffL-C SSN: L-C DOB:
L-C Class and Shares: L-C Officer_2: OffL-C Stockholder_2: OffL-C
Trustee_2: OffL-C Beneficiary_2: OffL-C Last Name_2: L-C First
Name_2: L-C MI_2: L-C Title_2: L-C OOC 2: OffL-C SSN 2: L-C DOB 2:
L-C Class and Shares 2: L-C Officer_3: OffL-C Director_3: OffL-C
Stockholder_3: OffL-C Trustee_3: OffL-C Beneficiary_3: OffL-C Last
Name_3: L-C First Name_3: L-C MI_3: L-C Title_3: L-C SSN 3: L-C OOC
3: OffL-C DOB 3: L-C Class and Shares 3: L-C Officer_4: OffL-C
Director_4: OffL-C Stockholder_4: OffL-C Trustee_4: OffL-C
Beneficiary_4: OffL-C Last Name_4: L-C First Name_4: L-C MI_4: L-C
Title_4: L-C SSN 4: L-C OOC 4: OffL-C DOB 4: L-C Class and Shares
4: L-C Officer_5: OffL-C Director_5: OffL-C Stockholder_5: OffL-C
Trustee_5: OffL-C Beneficiary_5: OffL-C Last Name_5: L-C First
Name_5: L-C MI_5: L-C Title_5: L-C OOC 5: OffL-C SSN 5: L-C DOB 5:
L-C Class and Shares 5: L-C Officer_6: OffL-C Director_6: OffL-C
Stockholder_6: OffL-C Trustee_6: OffL-C Beneficiary_6: OffL-C Last
Name_6: L-C First Name_6: L-C MI_6: L-C Title_6: L-C OOC 6: OffL-C
SSN 6: L-C DOB 6: L-C Class and Shares 6: L-C Officer_7: OffL-C
Director_7: OffL-C Stockholder_7: OffL-C Trustee_7: OffL-C
Beneficiary_7: OffL-C Last Name_7: L-C First Name_7: L-C MI_7: L-C
Title_7: L-C SSN 7: L-C OOC 7: OffL-C DOB 7: L-C Class and Shares
7: L-C Officer_8: OffL-C Director_8: OffL-C Stockholder_8: OffL-C
Trustee_8: OffL-C Beneficiary_8: OffL-C Last Name_8: L-C First
Name_8: L-C MI_8: L-C Title_8: L-C OOC 8: OffL-C SSN 8: L-C DOB 8:
L-C Class and Shares 8: L-C Officer_9: OffL-C Director_9: OffL-C
Stockholder_9: OffL-C Trustee_9: OffL-C Beneficiary_9: OffL-C Last
Name_9: L-C First Name_9: L-C MI_9: L-C Title_9: L-C SSN 9: L-C OOC
9: OffL-C DOB 9: L-C Class and Shares 9: L-C Officer_10: OffL-C
Director_10: OffL-C Stockholder_10: OffL-C Trustee_10: OffL-C
Beneficiary_10: OffL-C Last Name_10: L-C First Name_10: L-C MI_10:
L-C Title_10: L-C OOC 10: OffL-C SSN 10: L-C DOB 10: L-C Class and
Shares 10: L-C Officer_11: OffL-C Director_11: OffL-C
Stockholder_11: OffL-C Trustee_11: OffL-C Beneficiary_11: OffL-C
Last Name_11: L-C First Name_11: L-C MI_11: L-C Title_11: L-C SSN
11: L-C OOC 11: OffL-C DOB 11: L-C Class and Shares 11: L-C
Officer_12: OffL-C Director_12: OffL-C Stockholder_12: OffL-C
Trustee_12: OffL-C Beneficiary_12: OffL-C Last Name_12: L-C First
Name_12: L-C MI_12: L-C Title_12: L-C OOC 12: OffL-C SSN 12: L-C
DOB 12: L-C Class and Shares 12: L-LLC FEIN: L-LLC Business Entity
Name: 3 Filing Number: L-LLC Member Managed: OffL-LLC Manager
Managed: OffL-LLC Date Filed: State: L-LLC Mem: Units:
L-LLC Officer: OffL-LLC Manager: OffL-LLC Member: OffL-LLC Last
Name: L-LLC First Name: L-LLC MI: L-LLC Title: L-LLC OOC: OffL-LLC
SSN: L-LLC DOB: L-LLC Units Held: L-LLC Officer 2: OffL-LLC Manager
2: OffL-LLC Member 2: OffL-LLC Last Name_2: First Name_2: L-LLC
MI_2: L-LLC Title_2: L-LLC OOC 2: OffL-LLC SSN Out of Country_2:
L-LLC Date of Birth mmddyyyy_2: L-LLC Percentage Membership or
Units Held_2: L-LLC Officer 3: OffL-LLC Manager 3: OffL-LLC Member
3: OffL-LLC L-LLC Last Name_3: L-LLC First Name_3: L-LLC MI_3:
L-LLC Title_3: L-LLC OOC 3: OffL-LLC SSN Out of Country_3: L-LLC
Date of Birth mmddyyyy_3: L-LLC Percentage Membership or Units
Held_3: L-LLC Officer 4: OffL-LLC Manager 4: OffL-LLC Member 4:
OffL-LLC Last Name_4: L-LLC First Name_4: L-LLC MI_4: L-LLC
Title_4: L-LLC OOC 4: OffL-LLC SSN Out of Country_4: L-LLC Date of
Birth mmddyyyy_4: L-LLC Percentage Membership or Units Held_4:
L-LLC Officer 5: OffL-LLC Manager 5: OffL-LLC Member 5: OffL-LLC
Last Name_5: First Name_5: MI_5: Title_5: L-LLC OOC 5: OffSSN Out
of Country_5: Date of Birth mmddyyyy_5: Percentage Membership or
Units Held_5: L-LLC Officer 6: OffL-LLC Manager 6: OffL-LLC Member
6: OffL-LLC Last Name_6: L-LLC First Name_6: L-LLC MI_6: L-LLC
Title_6: L-LLC OOC 6: OffL-LLC SSN Out of Country_6: L-LLC Date of
Birth mmddyyyy_6: L-LLC Percentage Membership or Units Held_6:
L-LLC Officer 7: OffL-LLC Manager 7: OffL-LLC Member 7: OffL-LLC
Last Name_7: L-LLC First Name_7: L-LLC MI_7: L-LLC Title_7: L-LLC
OOC 7: OffL-LLC SSN Out of Country_7: L-LLC Date of Birth
mmddyyyy_7: L-LLC Percentage Membership or Units Held_7: L-LLC
Officer 8: OffL-LLC Manager 8: OffL-LLC Member 8: OffL-LLC Last
Name_8: L-LLC First Name_8: L-LLC MI_8: L-LLC Title_8: L-LLC OOC 8:
OffL-LLC SSN Out of Country_8: L-LLC Date of Birth mmddyyyy_8:
L-LLC Percentage Membership or Units Held_8: L-LLC Officer 9:
OffL-LLC Manager 9: OffL-LLC Member 9: OffL-LLC Last Name_9: L-LLC
First Name_9: L-LLC MI_9: L-LLC Title_9: L-LLC OOC 9: OffL-LLC SSN
Out of Country_9: L-LLC Date of Birth mmddyyyy_9: L-LLC Percentage
Membership or Units Held_9: L-LLC Officer 10: OffL-LLC Manager 10:
OffL-LLC Member 10: OffL-LLC Last Name_10: L-LLC First Name_10:
L-LLC MI_10: L-LLC Title_10: L-LLC OOC 10: OffL-LLC SSN Out of
Country_10: L-LLC Date of Birth mmddyyyy_10: L-LLC Percentage
Membership or Units Held_10: L-LLC Officer 11: OffL-LLC Manager 11:
OffL-LLC Member 11: OffL-LLC Last Name_11: L-LLC First Name_11:
L-LLC MI_11: L-LLC Title_11: L-LLC OOC 11: OffL-LLC SSN Out of
Country_11: L-LLC Date of Birth mmddyyyy_11: L-LLC Percentage
Membership or Units Held_11: L-LLC Officer 12: OffL-LLC Manager 12:
OffL-LLC Member 12: OffL-LLC Last Name_12: L-LLC First Name_12:
L-LLC MI_12: L-LLC Title_12: L-LLC OOC 12: OffL-LLC SSN Out of
Country_12: L-LLC Date of Birth mmddyyyy_12: L-LLC Percentage
Membership or Units Held_12: 1 L-P FEIN: L-P Business Entity Name:
L-P Filing Number: L-P Date Filed: L-P State: L-P GP: OffL-P LP:
OffL-P Last Name: L-P First Name: L-P MI: L-P Title: L-P OOC:
OffL-P SSN Out of Country: L-P Date of Birth mmddyyyy: L-P Percent
of Interest: L-P GP 2: OffL-P LP 2: OffL-P Last Name_2: L-P First
Name_2: L-P MI_2: L-P Title_2: L-P OOC 2: OffL-P SSN Out of
Country_2: L-P Date of Birth mmddyyyy_2: L-P Percent of Interest_2:
L-P GP 3: OffL-P LP 3: OffL-P Last Name_3: L-P First Name_3: L-P
MI_3: L-P Title_3: L-P SSN Out of Country_3: L-P OOC 3: OffL-P Date
of Birth mmddyyyy_3: L-P Percent of Interest_3: L-P GP 4: OffL-P LP
4: OffL-P Last Name_4: L-P First Name_4: L-P MI_4: L-P Title_4: L-P
SSN Out of Country_4: L-P OOC 4: OffL-P Date of Birth mmddyyyy_4:
L-P Percent of Interest_4: L-P GP 5: OffL-P LP 5: OffL-P Last
Name_5: L-P First Name_5: L-P MI_5: L-P Title_5: L-P OOC 5: OffL-P
SSN Out of Country_5: L-P Date of Birth mmddyyyy_5: L-P Percent of
Interest_5: L-P GP 6: OffL-P LP 6: OffL-P Last Name_6: L-P First
Name_6: L-P MI_6: L-P Title_6: L-P OOC 6: OffL-P SSN Out of
Country_6: L-P Date of Birth mmddyyyy_6: L-P Percent of Interest_6:
L-P GP 7: OffL-P LP 7: OffL-P Last Name_7: L-P First Name_7: L-P
MI_7: L-P Title_7: L-P SSN Out of Country_7: L-P OOC 7: OffL-P Date
of Birth mmddyyyy_7: L-P Percent of Interest_7: L-P GP 8: OffL-P LP
8: OffL-P Last Name_8: L-P First Name_8: L-P MI_8: L-P Title_8: L-P
OOC 8: OffL-P SSN Out of Country_8: L-P Date of Birth mmddyyyy_8:
L-P Percent of Interest_8: L-P GP 9: OffL-P LP 9: OffL-P Last
Name_9: L-P First Name_9: L-P MI_9: L-P Title_9: L-P SSN Out of
Country_9: L-P OOC 9: OffL-P Date of Birth mmddyyyy_9: L-P Percent
of Interest_9: L-P GP 10: OffL-P LP 10: OffL-P Last Name_10: L-P
First Name_10: L-P MI_10: L-P Title_10: L-P SSN Out of Country_10:
L-P OOC 10: OffL-P Date of Birth mmddyyyy_10: L-P Percent of
Interest_10: L-P GP 11: OffL-P LP 11: OffL-P Last Name_11: L-P
First Name_11: L-P MI_11: L-P Title_11: L-P SSN Out of Country_11:
L-P OOC 11: OffL-P Date of Birth mmddyyyy_11: L-P Percent of
Interest_11: L-P GP 12: OffL-P LP 12: OffL-P Last Name_12: L-P
First Name_12: L-P MI_12: L-P Title_12: L-P OOC 12: OffL-P SSN Out
of Country_12: L-P Date of Birth mmddyyyy_12: L-P Percent of
Interest_12: L-PHS Trade Name: L-PHS Location Address: L-PHS
Single: OffL-PHS Married: OffL-PHS Divorced: OffL-PHS Widow:
OffL-PHS Social Security Number: L-PHS Issuing State Drivers
License Number: L-PHS Date of Birth mmddyyyy: L-PHS Full Legal Name
Last First Middle: L-PHS Place of Birth: L-PHS Email Address: L-PHS
Spouse Full Legal Name: L-PHS Spouse SSN: L-PHS Spouse Issuing
State Driver License Number: L-PHS Spouse Date of Birth: L-PHS
Spouse Place of Birth City State Country_2: L-PHS Live With:
OffL-PHS Other Full legal name Last First Middle: L-PHS Other
Social Security Number: L-PHS Other Issuing State Driver License
No: L-PHS Other Date of Birth mmddyyyy_3: L-PHS Other Relationship:
L-PHS Number and StreetRow1: L-PHS City State ZIPRow1: L-PHS From
mmyyyyRow1: L-PHS Number and StreetRow2: L-PHS City State ZIPRow2:
L-PHS From mmyyyyRow2: L-PHS To Date: L-PHS Number and StreetRow3:
L-PHS City State ZIPRow3: L-PHS From mmyyyyRow3: L-PHS To Date 2:
L-PHS Business Phone No: L-PHS Residential Phone No: L-PHS Mobile
Phone No: L-PHS Citizen: OffL-PHS Native Born: OffL-PHS
Naturalized: OffL-PHS A#: L-PHS Explanation: L-PHS Name of
EmployerCompanyRow1: L-PHS Address Street City State ZIPRow1: L-PHS
Position HeldBusiness TypeRow1: L-PHS From mmyyyyRow1_2: L-PHS Name
of EmployerCompanyRow2: L-PHS Address Street City State ZIPRow2:
L-PHS Position HeldBusiness TypeRow2: L-PHS From mmyyyyRow2_2:
L-PHS PRESENTRow1_2: L-PHS Name of EmployerCompanyRow3: L-PHS
Address Street City State ZIPRow3: L-PHS Position HeldBusiness
TypeRow3: L-PHS From mmyyyyRow3_2: L-PHS PRESENTRow2_2: L-PHS Name
of EmployerCompanyRow4: L-PHS Address Street City State ZIPRow4:
L-PHS Position HeldBusiness TypeRow4: L-PHS From mmyyyyRow4: L-PHS
PRESENTRow3: L-PHS Name of EmployerCompanyRow5: L-PHS Address
Street City State ZIPRow5: L-PHS Position HeldBusiness TypeRow5:
L-PHS From mmyyyyRow5: L-PHS PRESENTRow4: L-PHS Name of
EmployerCompanyRow6: L-PHS Address Street City State ZIPRow6: L-PHS
Position HeldBusiness TypeRow6: L-PHS From mmyyyyRow6: L-PHS
PRESENTRow5: L-PHS Amount Invested 1: L-PHS Original Source of
Investment loans previous employment etc: L-PHS Amount Invested 2:
L-PHS Original Source of Investment loans previous employment
etc_2: L-PHS Amount Invested 3: L-PHS Original Source of Investment
loans previous employment etc_3: L-PHS Amount Invested 4: L-PHS
Original Source of Investment loans previous employment etc_4:
L-PHS Amount Invested 5: L-PHS Original Source of Investment loans
previous employment etc_5: L-PHS Amount Invested 6: L-PHS Original
Source of Investment loans previous employment etc_6: L-PHS Amount
Invested 7: L-PHS TOTAL AMOUNT OF PERSONAL INVESTMENT: L-PHS Sig
Box NAME: L-C Director_2: Off
