Schedule Reg-1-C - Cigarette Products Information Form Page 2

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Step 5: Provide additional information regarding owners, officers, and shareholders
Part 2: Businesses
Part 1: Individuals - owner, officer, manager, director
a
_________________________________
____-____________
a
___________________________________ _________________
Legal name
FEIN
Legal name
Title
______________________________________________________
______________________________________________________
Home address - No PO Box number
City
State
ZIP
Legal address
City
State
ZIP
____ / ____ / ________
(______) ______ - ________
Date of birth
Phone
(______) ______ - ________
______
Ownership percentage:
_______ - _____ - _________
______
Phone
Ownership percentage:
Social Security number
b
___________________________________ _________________
b
_________________________________
____-____________
Legal name
Title
Legal name
FEIN
______________________________________________________
Home address - No PO Box number
City
State
ZIP
______________________________________________________
____ / ____ / ________
(______) ______ - ________
Legal address
City
State
ZIP
Date of birth
Phone
(______) ______ - ________
______
_______ - _____ - _________
______
Ownership percentage:
Ownership percentage:
Social Security number
Phone
c
___________________________________ _________________
Part 3: Corporate stockholders owning more than 5%
Legal name
Title
______________________________________________________
Home address - No PO Box number
City
State
ZIP
a
___________________________________ _________________
Legal name
Title
____ / ____ / ________
(______) ______ - ________
Date of birth
Phone
______________________________________________________
Home address - No PO Box number
City
State
ZIP
_______ - _____ - _________
______
Ownership percentage:
Social Security number
____ / ____ / ________
(______) ______ - ________
Date of birth
Phone
d
___________________________________ _________________
_______ - _____ - _________
______
Ownership percentage:
Legal name
Title
Social Security number
______________________________________________________
Home address - No PO Box number
City
State
ZIP
b
___________________________________ _________________
____ / ____ / ________
(______) ______ - ________
Legal name
Title
Date of birth
Phone
______________________________________________________
_______ - _____ - _________
______
Ownership percentage:
Home address - No PO Box number
City
State
ZIP
Social Security number
____ / ____ / ________
(______) ______ - ________
Date of birth
Phone
e
___________________________________ _________________
_______ - _____ - _________
______
Ownership percentage:
Legal name
Title
Social Security number
______________________________________________________
Home address - No PO Box number
City
State
ZIP
c
___________________________________ _________________
____ / ____ / ________
(______) ______ - ________
Legal name
Title
Date of birth
Phone
______________________________________________________
_______ - _____ - _________
______
Ownership percentage:
Home address - No PO Box number
City
State
ZIP
Social Security number
____ / ____ / ________
(______) ______ - ________
Date of birth
Phone
f
___________________________________ _________________
Legal name
Title
_______ - _____ - _________
______
Ownership percentage:
Social Security number
______________________________________________________
Home address - No PO Box number
City
State
ZIP
____ / ____ / ________
(______) ______ - ________
Date of birth
Phone
_______ - _____ - _________
______
Ownership percentage:
Social Security number
*045102110*
Schedule REG-1- C (N-04/10)
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