Free 320DisclosureofOwnershipCorporation - Louisiana

JAY DARDENNE SECRETARY OF STATE

STATE OF LOUISIANA SECRETARY OF STATE

Commercial (225) 925-4704 (225) 922-0435 Fax Administrative Services (225) 925-4704 (225) 925-4726 Fax Uniform Commercial Code (225) 922-1193 (225) 922-0452 Fax

TRANSMITTAL INFORMATION For All Business Filings

Business Name (List exactly as it appears in documents)

Name of person filing document (evidence of filing will be mailed to this person, at address below)

Address

City

State

Zip Code

Daytime phone number

Fax number

Email address

NOTE: Louisiana Law requires all Louisiana notaries to print or type their name and notary or bar roll number on the document.

Mailing Address: P. O. Box 94125, Baton Rouge, LA * 70804-9125 Office Location: 8585 Archives Ave., Baton Rouge, LA * 70809 Web Site Address: www.sos.louisiana.gov
SS984 Rev. 10/08

Jay Dardenne Secretary of State

DISCLOSURE OF OWNERSHIP
(R.S. 12:25 E, 12:205 E and 12:304 A (II))
Enclose $20 filing fee Make remittance payable to Secretary of State Do Not Send Cash Return to: Commercial Division P. O. Box 94125 Baton Rouge, LA 70804-9125 Phone (225) 925-4704 Web Site: www.sos.louisiana.gov

State of

Parish/County of

BEFORE ME, the undersigned Notary in and for the parish/county herein above shown, personally came and appeared the undersigned who, after being duly sworn, did depose and say that:

Corporation Name

is contracting with the state and listed below are the names and addresses of all persons or corporate entities who hold ownership interest of five percent or more in the corporation or who hold by proxy the voting power of five percent or more in the corporation and, if anyone is holding stock in his own name that actually belongs to another, the name of the person for whom held, including stock held pursuant to a counter letter. 1. Persons or corporate entities owning 5% or more:

Name

Address

Name

Address

Name

Address

2.

Persons or corporate entities who hold by proxy the voting power of 5% or more:

Name

Address

Name

Address

Name

Address

3.

Stock held for others and for whom held:

Name

Address

For Whom Held

Address

Name

Address

For Whom Held

Address

Name

Address

For Whom Held

Address

NOTARY NAME MUST BE TYPED OR PRINTED WITH NOTARY #
Sworn to and subscribed before me, the undersigned Notary Public, on this date:

Corporation Representative
SS320 Rev. 03/08

Notary Signature
(See instructions on back)

INSTRUCTIONS

1.

This form is be used when an existing corporation intends to contract with the state. This requirement does not apply to non profit corporations organized on a "non stock" basis, any agreement entered between the state and a corporation for electric or gas service, publicly traded corporations, or state chartered banks. You will receive a copy marked "received and filed" by the Secretary of State. You may furnish a photostatic copy of the "filed" form to the appropriate state agency.

2.