(C) The name, address and number of membership interests owned by each member:
Name
Address
Degree of
Membership
Kindred
Interest
____________________________
___________________________________________
__________
___________
____________________________
___________________________________________
__________
___________
____________________________
___________________________________________
__________
___________
____________________________
___________________________________________
__________
___________
____________________________
___________________________________________
__________
___________
____________________________
___________________________________________
__________
___________
____________________________
___________________________________________
__________
___________
(Total) _______________
________________________.
_______________________________________________
Dated
(Signature)
___________________________
______________________________________________
STATE OF
(Title)
_________________________
COUNTY OF
On this the _______ day of __________________________ , 20_____, before me, _____________________________________________________
personally appeared ______________________________________________________________________________, known to me, or proved to me,
to be the ___________________________________________________________ of the corporation that is described in and that executed the within
instrument and acknowledged to me that such corporation executed the same.
____________________________________
______________________________________________
My Commission Expires
(Notary Public)
(Notarial Seal)