Form Lotapp - Lottery Application Page 2

Corporate Statement (includes corporations, LLCs and LLPs)

The stockholders, members/partners are (please print):

Social Security

Date

Number

Name

Address

Number

of Birth

of Shares

The officers and directors of the corporation are (please print):

Name

Address

Title

I, _______________________________________________ , declare under penalty of false swearing that the information

Print name

on this corporate statement is true and complete.

Signature __________________________________________________ Date _____________________

Please attach additional pages if necessary.

Page 2

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Parent category: Financial