Ohio Department Of Commerce - Limited Liability Company Disclosure Form Page 2
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DLC4032 (LIMITED LIABILITY COMPANY DISCLOSURE FORM)
SECTION C.
(CONTINUED)
List the managing members and all persons with a 5% or greater membership or voting interest in the LLC.
THE INDIVIDUALS LISTED BELOW MUST HAVE A BACKGROUND CHECK PERFORMED BY BCI&I AND SUBMIT A PERSONAL HISTORY BACKGROUND
FORM. PLEASE READ “BACKGROUND CHECK INFORMATION” DLC4191.
3) Name
Social Security No. (if individual)
Check All That Apply
Managing Member
Residence Address
Tax Identification No. (if applicable)
Voting interest
%
City and State
Telephone No.
Membership interest
%
Birthdate
Zip Code
4) Name
Social Security No. (if individual)
Check All That Apply
Residence Address
Tax Identification No. (if applicable)
Managing Member
City and State
Voting interest
%
Telephone No.
Birthdate
Zip Code
Membership interest
%
5) Name
Social Security No. (if individual)
Check All That Apply
Managing Member
Residence Address
Tax Identification No. (if applicable)
Telephone No.
City and State
Voting interest
%
Birthdate
Zip Code
Membership interest
%
6) Name
Social Security No. (if individual)
Check All That Apply
Residence Address
Managing Member
Tax Identification No. (if applicable)
City and State
Voting interest
%
Telephone No.
Zip Code
Birthdate
Membership interest
%
7) Name
Social Security No. (if individual)
Check All That Apply
Managing Member
Residence Address
Tax Identification No. (if applicable)
Voting interest
%
City and State
Telephone No.
Birthdate
Membership interest
%
Zip Code
8) Name
Social Security No. (if individual)
Check All That Apply
Managing Member
Residence Address
Tax Identification No. (if applicable)
Voting interest
%
City and State
Telephone No.
Birthdate
Membership interest
%
Zip Code
9) Name
Social Security No. (if individual)
Check All That Apply
Residence Address
Managing Member
Tax Identification No. (if applicable)
City and State
Voting interest
%
Telephone No.
Birthdate
Zip Code
Membership interest
%
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