PARTNERSHIPS/CORPORATIONS TRADE NAME: FORM L-106-PC (8/2005) 1A. Indicate type of ownership and complete the information below: Corporation Limited Liability Company Partnership Limited Partnership Limited Liability Partnership B. Federal Employer’s I.D. No.: C. Entity Name: D. Charter No.: Date Approved: / / State: FOR ALL OFFICER(S), PARTNER(S), DIRECTOR(S), MANAGER(S), STOCKHOLDER(S) AND MEMBER(S). E. Number and class of shares, memberships or units issued: 2. COMPLETE THE FOLLOWING PER INSTRUCTIONS: Social Security Number - Issuing State and Driver’s License Number Full Legal Name (Last, First Middle) Officer Partner Director/ Manager Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Residential Address Social Security Number - Full Legal Name (Last, First Middle) Officer Partner Director/ Manager Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Residential Address Social Security Number - Issuing State and Driver’s License Number Officer Partner Director/ Manager Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Residential Address Full Legal Name (Last, First Middle) Officer Partner Director/ Manager Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Residential Address Social Security Number - Full Legal Name (Last, First Middle) Officer Partner Director/ Manager Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Residential Address Social Security Number - Full Legal Name (Last, First Middle) Residential Address Officer Partner Director/ Manager Date of Birth (mm/dd/yyyy) / / Stockholder/ Member State Zip Code (9 digits) - Class & No. Shares Held or % Memberships or % Interest State Zip Code (9 digits) - Class & No. Shares Held or % Memberships or % Interest State Zip Code (9 digits) - Class & No. Shares Held or % Memberships or % Interest Title City Issuing State and Driver’s License Number Class & No. Shares Held or % Memberships or % Interest Title City Issuing State and Driver’s License Number Zip Code (9 digits) - Title City Issuing State and Driver’s License Number State Title City Full Legal Name (Last, First Middle) Social Security Number - Title City Issuing State and Driver’s License Number Class & No. Shares Held or % Memberships or % Interest State Zip Code (9 digits) - Class & No. Shares Held or % Memberships or % Interest Title City State Zip Code (9 digits) - (IF YOU NEED ADDITIONAL SPACE FOR MORE NAMES, USE ADDITIONAL COPIES OF THIS PAGE) American LegalNet, Inc. www.FormsWorkflow.com