ATTACHMENT B
PUBLIC INTEGRITY BUSINESS DISCLOSURE
PUBLIC INTEGRITY DISCLOSURE
APPLICANT DISCLOSURE FORM
1. Name of Entity
2. Address of Entity (Principal Place of Business)
3. Local or California Address (if different than #2)
4. State where Entity is Registered with Secretary of State If other than California, is the Entity also registered in California? F Yes F No
5. Type of Entity
F Corporation F Limited Liability Company F Partnership F Trust F Other (please specify)
6. Officers, Directors, Members, Managers, Trustees, Other Fiduciaries (please specify) Note: If any response is not a natural person, please identify all officers, directors, members, managers and other fiduciaries for the member, manager, trust, or other entity
________________________ F Officer F Director F Member F Manager
[name] F General Partner F Limited Partner
FOther
___________________________
_______________________________ F Officer F Director F Member F Manager [ n a m e ] F General Partner F Limited Partner
F Other
__________________________
________________________________ F Officer F Director F Member F Manager Universal Green LLC
17989 Corkill Rd #63, Desert Hot Springs, CA 92241
California
Salvador Moreno
Sarita Y Ramos Rodriguez
Raymundo Vega
[name] F General Partner F Limited Partner
F Other
__________________________
7. Owners/Investors with a 5% beneficial interest in the Applicant Entity or a related entity
EXAMPLE
JANE DOE
[name of owner/investor]
50%, ABC COMPANY, Inc.
[percentage of beneficial interest in entity
and name of entity]
A.
[name of owner/investor]
[percentage of beneficial interest in entity
and name of entity]
B.
[name of owner/investor]
[percentage of beneficial interest in entity
and name of entity]
C.
[name of owner/investor]
[percentage of beneficial interest in entity
and name of entity]
D.
[name of owner/investor] [percentage of beneficial interest in entity and name of entity]
E.
[name of owner/investor] [percentage of beneficial interest in entity and name of entity]
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
Signature of Disclosing Party, Printed Name, Title Date Salvador Moreno
Sarita Y Ramos Rodriguez
Raymundo Vega
33.33%
33.33%
33.33%
inted Name, Title
Salvador Moreno, Member //26