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Revised 02/04

UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF MICHIGAN
In re: Case No. ______________ Chapter _______________ Hon. _________________ Debtor ____________________________________/ STATEMENT OF DEBTOR REGARDING CORPORATE OWNERSHIP

G

The following entities directly or indirectly own 10% or more of any class of the debtor's equity interest: Name:__________________________________________________________ Address:________________________________________________________ Name:__________________________________________________________ Address:________________________________________________________ Name: _________________________________________________________ Address:________________________________________________________ Name:_________________________________________________________ Address:_______________________________________________________ (For additional names, attach an addendum to this form)

G

There are no entities that directly or indirectly own 10% or more of any class of the debtor's equity interest.

I declare under penalty of perjury that the foregoing is true and correct.

Dated:__________ Signature of Authorized Individual For Corporation Debtor

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