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Gc/bc Form 105 - Schedule C - Corporation Statement - Nys Gaming Commission - Division Of Charitable Gaming Page 2

List names and addresses of all stockholders and the number of shares held by each.

f necessary use a separate sheet of paper)

Name

Street Address

City

State Zip Code # of Shares Held

______________________ ________________________ ____________________ ______ ________ ______________

Does any person not named in the application herein, or, if a corporate applicant, any person not an officer, director or

stockholder of such corporation have any interest, financial, proprietary or other, direct or indirect, in the business to be

licensed, or has made any loan to the applicant for said business or have any lien mortgage on the fixtures in the business?

____yes ____no

Has the applicant or (if a partnership) any of the partners or (if a corporation) any of the officers, directors or stockholders

ever had any proprietary, equitable or credit interest in any premises leased for the conduct of games of chance and/or

bingo? ____yes ____no

Does any stockholder hold all or any part of his or her shares as agent, nominee, trustee or in any fiduciary capacity for or

on behalf of any disclosed or undisclosed person, firm or corporation? If yes, give details on a separate sheet of paper.

ATTACH A COPY OF EACH: 1. Agreement creating the entity and any supplement or changes. (new applicants only)

2. Most recent financial statement (balance sheet or profit & loss statement).

*********************************************************

________________________________________ , __________________________being duly sworn and says that he/she

(Print Name of Applicant)

(Title)

is the person above named, that he/she has read the foregoing statement and the answer therein noted, and that such

answers are true and that he/she has personally affixed his/her signature to this affidavit.

Sworn to before me on this ___________ day of ________________________, 20______

_____________________________________________________

NOTARY STAMP

(Signature of Applicant)

_____________________________________________________

(Signature of Notary Public)

Page 2 of 2

Form 105 (Rev. 1/2016)

Gc/bc Form 105 - Schedule C - Corporation Statement - Nys Gaming Commission - Division Of Charitable Gaming Page 2