EPI 1306
PAGE A1
EPI 1306
Beneficial Ownership
Addendum
Provide the following information for each individual who owns, directly or indirectly, 25% or more of the equity interest of your business.
OWNERS/OFFICERS/PARTNERS
Owner/Principal #3 (PRINT)
Equity Ownership
%
Social Security #
Telephone #
Residence Address
City, State & ZIP Code
Date of Birth
Driver’s License #
State of Issuance
Has owner/principal disclosed above filed bankruptcy or been subject to an involuntary bankruptcy?
OWNERS/OFFICERS/PARTNERS
Owner/Principal #4 (PRINT)
Equity Ownership
%
Social Security #
Telephone #
Residence Address
City, State & ZIP Code
Date of Birth
Driver’s License #
State of Issuance
Has owner/principal disclosed above filed bankruptcy or been subject to an involuntary bankruptcy?
OWNERS/OFFICERS/PARTNERS
Owner/Principal #5 (PRINT)
Equity Ownership
%
Social Security #
Telephone #
Residence Address
City, State & ZIP Code
Date of Birth
Driver’s License #
State of Issuance
Has owner/principal disclosed above filed bankruptcy or been subject to an involuntary bankruptcy?
OWNERS/OFFICERS/PARTNERS
Owner/Principal #6 (PRINT)
Equity Ownership
%
Social Security #
Telephone #
Residence Address
City, State & ZIP Code
Date of Birth
Driver’s License #
State of Issuance
Has owner/principal disclosed above filed bankruptcy or been subject to an involuntary bankruptcy?
7800 Congress Avenue, Suite 112
Boca Raton, Florida 33487
7800 Congress Avenue, Suite 112
Boca Raton, Florida 33487
Electronic Payments is a registered Independent Sales Organization of Wells Fargo Bank, N.A., Concord, CA