Affidavit of Ownership
Before me, the undersigned authority, personally appeared and after being duly sworn, deposes and says:
I, ________________________________________________hereby attest to ownership of the business entity
(Owner or Legal Representative - Print Name)
below:
Legal Name of Business Entity: _____________________________________________________________________________
Legal Type Sole Proprietorship Partnership Limited Liability Company Corporation
Nonprofit Corporation Other ____________________________________________________________
If the entity is a corporation, partnership, or LLC, list each individual owner and percent of ownership.
Owner (Print Name) % Owned Owner (Print Name) % Owned
__________________________________ _________ __________________________________ _________
__________________________________ _________ __________________________________ _________
__________________________________ _________ __________________________________ _________
If the business applying is owned by a corporation or another legal entity, please specify its name as well:
____________________________________________________________________________________ _________
I have read the foregoing Affidavit, and to the best of my knowledge it is true and correct. (All owners must sign below)
__________________________________________ _________________________________________ ____________________
Print Name Signature Date
__________________________________________ _________________________________________ ____________________
Print Name Signature Date
__________________________________________ _________________________________________ ____________________
Print Name Signature Date
__________________________________________ _________________________________________ ____________________
Print Name Signature Date
__________________________________________ _________________________________________ ____________________
Print Name Signature Date
__________________________________________ _________________________________________ ____________________
Print Name Signature Date
Notary Public
State of _____________________, in the country of ____________________ on _____ day, of the ________________ month, in the year of
___________, before me appeared (name) __________________________________________________ and stated that he/she is the (title)
___________________ of (name of organization) ___________________________________________ and that the information provided
on this form is true and correct. My commission expires on (date): ____________________ Notary Public: __________________________
1 208-2024-01-01
