LISTED BUSINESS CONCERN DISCLOSURE FORM INSTRUCTIONS 1. WHO MUST COMPLETE THIS FORM. This form must be completed for all listed business concerns. 2. ALL QUESTIONS MUST BE ANSWERED. Read every question carefully before answering. Answer every question completely. Do not leave blank spaces. If a question does not apply, enter “Not Applicable” or “N/A” in the space provided for an answer. If there is nothing to disclose in answer to a particular question, enter “None” in the space provided for an answer. 3. ANSWER COMPLETELY AND TRUTHFULLY. Failure to answer any question completely may result in the statement being returned for supplementation. If the answer to a question in this form is identical to an answer given to a previous question in the form, you may answer the later question by writing “Same as ____.” For example, if the answer to Question 3 is the same as the answer to Question 2, you may answer Question 3 by writing “Same as 2.” WARNING FRAUDULENT, DECEPTIVE OR MISLEADING ANSWERS ON DISCLOSURE STATEMENTS MAY RESULT IN THE DENIAL OR REVOCATION OF AN OEPA LICENSE. IN ADDITION, ANY PERSON WHO MAKES FALSE OR MISLEADING STATEMENTS ON THIS FORM MAY BE SUBJECT TO CRIMINAL PROSECUTION. Be especially careful not to leave out information in a way that might create an impression that you are trying to hide it. For example, a minor criminal conviction will probably not disqualify you or your company from being licensed -- but attempting to conceal the conviction may lead to a finding of untrustworthiness, and result in disqualification. Omitting such information from this form, even unintentionally, may result in your trustworthiness being questioned. Even if the question is resolved in your favor, an application may be delayed while the inquiry goes forward. If you are unsure of, or do not remember the answer to a question, indicate this in some way -- for example, by writing "Do not remember." This may result in additional inquiries from the Director or the Attorney General, but it will avoid the implication that you are trying to conceal information. However, you should not answer “Do not remember,” or similar wording, simply because the information may not be immediately at hand. You are expected to make reasonable efforts to check your records so that you can answer the question completely 4. ADDITIONAL SPACE. If you need additional space to answer a question, use plain 8 ½ ” by 11” paper. Insert additional pages immediately following the page on which the question you are answering appears. Be sure to indicate your answer is "continued on next page," and indicate on the American LegalNet, Inc. www.FormsWorkflow.com additional page what question is being answered there. When you have finished answering all questions, and have attached all additional pages, consecutively number each page at the top right corner - including the additional pages. Pages of the original form which need to be renumbered as a result of adding pages should be renumbered at the space provided after "Your Page No.____." 5. TYPE OR PRINT YOUR ANSWERS. Type or print in legible block letter style. IF YOU HAVE GENERAL NON-INTERPRETIVE QUESTIONS ABOUT HOW TO FILL OUT THIS FORM CALL THE OFFICE OF THE OHIO ATTORNEY GENERAL (614) 466-3843. SOCIAL SECURITY NUMBERS: Notice required under Section 7(b) of the Federal Privacy Act of 1974 Under Section 7(b) of the Privacy Act of 1974, 5 U.S.C. 552a (note), any government agency which requests an individual to disclose his Social Security account number must inform that individual whether the disclosure is mandatory or voluntary, by what statutory or other authority such number is solicited, and what uses will be made of it. The Ohio Environmental Protection Agency and the Ohio Attorney General are authorized to request Social Security numbers pursuant to Paragraph (D) of Section 3734.41 of the Revised Code, which defines the contents of disclosure statements. The Social Security number is used as a secondary identifier by the Ohio Bureau of Criminal Investigation when they conduct background identification, when the Bureau of Criminal Investigation conduct checks of criminal history records maintained by the state and federal governments, and as a cross-check against motor vehicle records. In specific investigations which may involve examination of particular records obtained from outside sources, the Social Security number might be used to determine whether the individual named in the records and the individual under investigation are the same or different persons. The listing of Social Security numbers on the disclosure forms is voluntary. Under Section 7(a) of the Privacy Act, the State of Ohio cannot deny or revoke a license or impose any penalty because of an individual's refusal to disclose a Social Security number. However, the absence of a Social Security number as a secondary identifier may delay processing and decisions on licensure because of necessary additional investigative time. Note that, the absence of a Social Security number may result in an individual initially being identified as having a criminal record which actually is that of another person. This again, may result in delays in the decision on licensure required by Revised Code Section 3734.40 et seq. ii American LegalNet, Inc. www.FormsWorkflow.com Page No. 1 Your Page No. _____ LISTED BUSINESS CONCERN DISCLOSURE FORM 1. FULL NAME OF THE LISTED BUSINESS CONCERN FOR WHICH THIS FORM IS COMPLETED: 1.a. Business Address: Number and Street City County State FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): NAME OF PERSON TO BE CONTACTED IN REFERENCE TO THIS FORM: Name 2. Title Provide the following information for each individual who is an officer, director, or partner of the business concern listed in Question l. Full Name Date of Birth Address Social Security No. American LegalNet, Inc. www.FormsWorkflow.com Page No. 2 Your Page No. _____ 3. Provide the following information for each individual who holds any equity in or debt liability of the business concern listed in Question 1, and the business concern listed in Question 1 is not a publicly traded corporation. Full Name 4. Date of Birth Address Social Security No. Provide the following information for each individual who holds more than 5% of the equity in or debt liability of the business concern listed in Question 1, and the business concern listed in Question 1 is a publicly traded corporation. Full Name Date of Birth Address Social Security No. American LegalNet, Inc. www.FormsWorkflow.com Page No. 3 Your Page No. 5. Provide the following information for each business concern, which is a partner of the business concern, listed in Question 1. Full Name 6. Address Federal Tax I. D. No. Provide the following information for each business concern which holds any equity in the business concern listed in Question 1, where the business concern listed in Question 1 is not a publicly traded corporation. Full Name Address Federal Tax I. D. No. American LegalNet, Inc. www.FormsWorkflow.com Page No. 4 Your Page No. ______ 7. Provide the following information for each business concern which holds any debt liability in a business concern listed in Question 1, where the business concern listed in Question 1 is not a publicly traded corporation. Full Name 8. Address Federal Tax I. D. No. Provide the following information for each business concern which holds more than 5% of the equity of a business listed in Question 1, where the business concern listed in Question 1 is a publicly traded corporation. Full Name Address Federal Tax I. D. No. American LegalNet, Inc. www.FormsWorkflow.com Page No. 5 Your Page No. ____ 9. Provide the following information for each business concern which holds more than 5% of the debt liability of a business listed in Question 1, where the business concern listed in Question 1 is a publicly traded corporation. Full Name Address Federal Tax I. D. No. American LegalNet, Inc. www.FormsWorkflow.com Page No. 6 Your Page No. ______ AFFIDAVIT STATE OF COUNTY OF ) ) ) I,_____________________________ , do hereby swear (or affirm) that the information in this Listed (Name) Business Disclosure Form is true and accurate to the best of my knowledge. I am aware that if any of the foregoing statement made by me is knowingly false, I am subject to criminal prosecution or civil action. Date: _______________________________ (Signature) (Type or print name here) Sworn to and subscribed before me this ________day of 20 . , Seal or authority of Notary Public Notary Public American LegalNet, Inc. www.FormsWorkflow.com Page No. 7 Your Page No. _____ RELEASE AUTHORIZATION To All Courts, Probation Departments, Selective Service Boards, Credit Bureaus, Employers, Educational Institutions, Banks, Financial and other such Institutions, and all Governmental Agencies - federal, state and local without exception both foreign and domestic. On behalf of I, (President, Chief Executive, Partner or Sole Proprietor) have authorized the Attorney General of Ohio to Conduct an investigation into the background of the said enterprise for the purpose of determining its suitability to hold a solid, infectious, or hazardous waste license, as provided under Sections 3734.40 - .47 of the Revised Code. Therefore, you are hereby authorized to release any and all information pertaining to the said enterprise, documentary or otherwise, as requested by an appropriate employee, agent or representative of the Attorney General. This authorization shall supersede and countermand any prior request or authorization to the contrary. A photostatic copy of this authorization will be considered as effective and valid as the original. (Signature) Sworn to and subscribed before me on this 20 . day of , Seal or authority of Notary Public Notary Public F:\EBIU\DISCLOSU\MASTERLI.WPD American LegalNet, Inc. www.FormsWorkflow.com