Form 558 - Change Of Ownership Name - State Of Ohio Page 2

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Complete new owner information
Name
Charter/License/Registration Number
(If applicable)
Address
Mailing Address
City
State
Zip Code
By signing and submitting this form to the Ohio Secretary of State, the undersigned hereby certifies that he
or she has the requisite authority to execute this document.
REQUIRED
Must be authenticated
Signature
Date
(signed) by an authorized
representative
Print Name
Form 558
Page 2 of 3
Last Revised: 12/01/2008

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