Revised 02/04 UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF MICHIGAN In re: Case No. ______________ Chapter _______________ Hon. _________________ Debtor ____________________________________/ STATEMENT OF DEBTOR REGARDING CORPORATE OWNERSHIP G The following entities directly or indirectly own 10% or more of any class of the debtor’s equity interest: Name:__________________________________________________________ Address:________________________________________________________ Name:__________________________________________________________ Address:________________________________________________________ Name: _________________________________________________________ Address:________________________________________________________ Name:_________________________________________________________ Address:_______________________________________________________ (For additional names, attach an addendum to this form) G There are no entities that directly or indirectly own 10% or more of any class of the debtor’s equity interest. I declare under penalty of perjury that the foregoing is true and correct. Dated:__________ Signature of Authorized Individual For Corporation Debtor Print Name Title American LegalNet, Inc. www.FormsWorkflow.com