State of Washington Business Licensing Service PO Box 9034 Olympia WA 98507-9034 1-800-451-7985 bls.dor.wa.gov UBI number Liquor/Lottery license number For validation only Change In Governing People, Percentage Owned and/or Stock/Unit Ownership (this does not replace your annual report) 03N-400-925-0003 * A different form is required to make changes to officers, members, managers or your Resident Agent with the Office of the Secretary of State. Please contact them at corps@sos.wa.gov or 360-725-0377. Amount Due Liquor........................$75.00 Change in more than 10% of stock, election of new officers or changes in members or managers. Marijuana.................. $75.00 All other Licenses......Required for all governing people and/or stock changes regardless of the amount of percentage of ownership. Make check payable to the Department of Revenue Total amount due $ $ $ $ NO FEE Ownership type Name Partnership Corporation LLC LP/LLP/LLLP Non Profit Corporation UBI Number ( ) Company telephone number FEIN Company mailing address (Street or route) ( Contact name (Last, First, Middle) City ) Contact telephone number State Zip code Contact email address Stock ownership (if applicable) Total stock authorized: Number of shares issued: Par value per share: At the completion of this change, the governing persons and/or stockholders will be: Title examples: owner, partner, president, vice president, secretary, treasurer, member, manager, director * Name (Last, First, Middle) Title Social security number Date of birth ( Home/business address (Street or route) City State Zip code ) Telephone number Date became owner/officer Number of shares owned Percent owned Date(s) issued or enter "pending" if not yet issued Name of spouse (Last, First, Middle) Spouse social security number Spouse date of birth Yes No * Is this person related to other officers who own 10 percent or more? (i.e. parent, stepparent, grandparent, spouse, children, brother, sister, stepchildren, adopted children or grandchildren) Name (Last, First, Middle) Title Social security number Date of birth ( ) Home/business address (Street or route) City State ZIP code Telephone number Date became owner/officer Number of shares owned Percent owned Date(s) issued or enter "pending" if not yet issued Name of spouse (Last, First, Middle) Is this person related to other officers who own 10 percent or more? Spouse social security number Spouse date of birth Yes No (i.e. parent, stepparent, grandparent, spouse, children, brother, sister, stepchildren, adopted children or grandchildren) Please continue on to the next page. To receive this document in an alternate format, please call 1-800-647-7706. Teletype (TTY) users may use the Washington Relay Service by calling 711. BLS 700-306 (11/8/16) American LegalNet, Inc. www.FormsWorkFlow.com Name (Last, First, Middle) Title Social security number Date of birth ( ) Home/business address (Street or route) City State Zip code Telephone number Date became owner/officer Number of shares owned Percent owned Date(s) issued or enter "pending" if not yet issued Name of spouse (Last, First, Middle) Is this person related to other officers who own 10 percent or more? Spouse social security number Spouse date of birth Yes No (i.e. parent, stepparent, grandparent, spouse, children, brother, sister, stepchildren, adopted children or grandchildren) Name (Last, First, Middle) Title Social security number Date of birth ( ) Home/business address (Street or route) City State Zip code Telephone number Date became owner/officer Number of shares owned Percent owned Date(s) issued or enter "pending" if not yet issued Name of spouse (Last, First, Middle) Is this person related to other officers who own 10 percent or more? Spouse social security number Spouse date of birth Yes No (i.e. parent, stepparent, grandparent, spouse, children, brother, sister, stepchildren, adopted children or grandchildren) If necessary, attach additional sheets using the same format as shown above. Removal of governing people Name of governing person or stockholder Social security number Date of birth Title Removal Date Name of governing person or stockholder Social security number Date of birth Title Removal Date Name of governing person or stockholder Social security number Date of birth Title Removal Date Name of governing person or stockholder Social security number Date of birth Title Removal Date Additional forms or documents may be required by the individual agency. Liquor Control Board (360) 664-1600 · Lottery (360) 753-2155 Certification Under penalty of perjury, I hereby certify there have been no changes in officers or stockholders that have not been reported, and that each officer and stockholder is the real party in interest with respect to his/her position and is not acting directly or indirectly as agent, employee or representative of any other person not reported. I certify on behalf of the corporation that it is understood a misrepresentation of fact is cause for rejection of this application or revocation of any license issued. Print Name Signature Date Title Phone # To receive this document in an alternate format, please call 1-800-647-7706. Teletype (TTY) users may use the Washington Relay Service by calling 711. BLS 700-306 (11/8/16) American LegalNet, Inc. www.FormsWorkFlow.com