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UBI number State of Washington Business …

Change In Governing People, Percentage Owned and/or Stock/Unit Ownership (this does not replace your annual report)Please continue on to the next page. * A different form is required to make changes to officers, members, managers or your Resident Agent with the Office of the Secretary of State . Please contact them at or receive this document in an alternate format, please call 1-800-647-7706. Teletype (TTY) users may use the Washington Relay Service by calling 700-306 (10/12/17) State of WashingtonBusiness Licensing Service PO Box 9034 Olympia WA UBI number Liquor/Lottery license number For validation only03N-400-925-0003 Ownership type Partnership Corporation LLC LP/LLP/LLLP Non Profit CorporationNameUBI NumberFEIN ( )Company mailing address (Street or route) City( )StateZip codeCompany telephone numberContact name (Last, First, Middle)Contact telephone numberContact email addressStock ownership (if applicable) At the completion of this change, the governing persons and/or stockholders will be: Title examples: owner, partner, president, vice president, secretary, treasurer, member, ma

Change In Governing People, Percentage Owned and/or Stock/Unit Ownership (this does not replace your annual report) Please continue on to the next page.

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