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8 <br />e.OTHER ENTITY: the officers, the members of the governing body, and eachperson having an interest of more than 10% <br />Name & Address Title and nature and percent of interest <br />6. Names, addresses, and the nature and percent of interest of each person or entity (notnamed in Item 5) who has a beneficial interest in any of the shareholders or investorsnamed in Item 5 which gives such person or entity more than a computed 10% interest inthe Applicant (for example, more than 20% of the stock in a corporation which holds50% of the stock of the Applicant; or more than 50% of the stock in a corporation whichholds 20% of the stock of the Applicant). <br />Name & Address Title and nature and percent of interest <br />7. Names of officers and directors, or trustees of any corporation or firm listed under Item 5or Item 6 above. <br />Name & Address Title and nature and percent of interest <br />Certification <br />I (We), Certify that this Statement for Public Disclosure is true and correct to the best of my (our) knowledge and belief. <br />Name Name <br />Signature Signature <br />Title Title <br />Date Date <br />(If the Applicant is an individual, this statement should be signed by such individual; if a partnership, it should be signed by one <br />of the partners; if a corporation or other entity, it should be signed by one of its chief officers having knowledge of the facts <br />required by this statement)