PDF-Owners mailing address City State Zip

Property location Street Route Hwy etc City State Zip Number of acres included in this applicationAgricultural Land Timber Land District Land Lot Sublot Bloc. On January 1 was any portion of this property used for commercial purposes or rented to another person or entity for more than 6 months Yes No Check your type of residence Singlefamily dwelling Duplex Townhouse Condominium Apartment Other Yes No On Account Opening Form for esident ndividuals 7KLV57347LV57347D57347PDFKLQH57347UHDGDEOH57347IRUP57361573473OHDVH57347DYRLG57347RYHUZULWLQJ57347ZKLOH5734757535OOLQJ57347WKH57347DSSOLFDWLRQ FOR SAVINGS ACCOUNT INDIVIDUALJOINT AND CURRENT ACCOUNT INDIVI On January 1 was any portion of this property used for commercial purposes or rented to another person or entity for more than 6 months Yes No Check your type of residence Singlefamily dwelling Duplex Townhouse Condominium Apartment Other Yes No On S Department of State REQUEST FOR AUTHEN TICATIONS SERVICE DS4194 022012 Name Last First MI SECTION 1 CUSTOMER CONTACT INFORMATION Email Case Type If Federal Agency Must Be Official Business City State ZIP Code SuffixPrefix Specify Extension brPage 2 05 per certificate Certified copy 3875 per document Long Form 3875 per certificate Courier Service 2000 Payment Type Submitted by Credit Card Submitted by Cheque Mail Visa American Express Mail In person Money Order In person MasterCard Fax Credit C 00 FILE NO DATE FILED Name of Businesses Street Address Ci ty State Zip Code REGISTERED OWNERS 1 2 Full NameCorpLLC Full NameCorpLLC Res ( ) To record additional vehicles, complete the reverse side of this form VEHICLE MAKE TITLE NUMBER LAST FOUR DIGITS OF VEHICLE IDENTIFICATION STATE MAILING ADDRESS CITY ZIP CODE COUNTRY RN-26S City: Subject Building: Number and Street Apartment or Room Number City, State, Zip Code Note: Notice Form RN-26-Long Form should be used to compute the Maximum Base Rent (MBR) for an apart Please Print SurnameGiven Names Mailing Address CityProvince/StateCountryPostal Code Civic Address (If different than above) CityProvince/StateCountryPostal Code Home NumberWork NumberFax NumberE-mail Intelligent Mail for Small Business (IMsb). Intelligent Mail. ®. for Small Business Tool. The IMsb tool is a new, . free . online tool specifically designed for small-volume . mailers. It’s a web based program. . CitizenVIP ESL Your Address Your Address What is your home address? Has your address changed since you sent in your application? What is your address right now? What is your current address? Where do you live? D D EMPLOYER SECTION – REQUIRED INFORMATION Federal ID Number:Business Name: Mailing Address:ddress Line 2:City:State:Zip Code:Business Phone:Ext. Fax NumberEmail Address (optional)If the a Contact Phone Number290Contact Phone Number4653140Contact Email Address hssemtcertalaskagovMailing AddressAlaska Dept of Health Social Services Office of the Commissioner3601 C Street Suite 902https/ REASON FOR SUBMITTING THIS FORMCheck OneSECTION A - TAX TYPESType of Registration Check all that apply New Business - Never Registered Add Additional Add Additional ATAP Ownership Sales and