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Treasurer Name: Last First Middle Date of Birth: Personal Address: Street City State ZIP Personal Telephone: C. Please provide the following information for a11 persons who singly or together with their spouse and his or her parents, brothers, sisters, or children, own or control an interest in said corporation or association in excess of five (5) percent: 1. Name: 'L ��" /� 1" '� �-C � V`� C� Last First Middle Date of Birth: Interest % Personal Address: Street City State ZIP Personal Telephone: 2. Name: Last First Middle Date of Birth: Interest % Personal Address: Street City State ZIP Personal Telephone: 3. Name: Last Date of Birth: Personal Address: Street Personal Telephone: 4. Name: Last Date of Sirth: Personal Address: Street Personal Telephone: Page 5 oi 10 City c�ry First Middle Interest % State ZIP First Middle Interest % State ZIP