GENERAL INFORMATION SHEET (GIS)

FOR THE YEAR 2020

STOCK CORPORATION
GENERAL INSTRUCTIONS:
1 FOR USER CORPORATION: THIS GIS SHOULD BE SUBMITTED WITHIN THIRTY (30) CALENDAR DAYS FROM THE DATE OF THE ANNUAL STOCKHOLDERS'
MEETING. DO NOT LEAVE ANY ITEM BLANK. WRITE "N.A." IF THE INFORMATION REQUIRED IS NOT APPLICABLE TO THE CORPORATION OR "NONE" IF
THE INFORMATION IS NON-EXISTENT. IF THE ANNUAL STOCKHOLDERS' MEETING IS HELD ON A DATE OTHER THAN THAT STATED IN THE BY-LAWS,
THE GIS SHALL BE SUBMITTED WITHIN THIRTY (30) CALENDAR DAYS FROM THE ACTUAL DATE OF THE ANNUAL STOCKHOLDERS' MEETING.

2 IF NO MEETING IS HELD, THE CORPORATION SHALL SUBMIT THE GIS NOT LATER THAN JANUARY 30 OF THE FOLLOWING YEAR. HOWEVER, SHOULD
AN ANNUAL STOCKHOLDERS' MEETING BE HELD THEREAFTER, A NEW GIS SHALL BE SUBMITTED/FILED.
3 THIS GIS SHALL BE ACCOMPLISHED IN ENGLISH AND CERTIFIED AND SWORN TO BY THE CORPORATE SECRETARY OF THE CORPORATION.
4 THE SEC SHOULD BE TIMELY APPRISED OF RELEVANT CHANGES IN THE SUBMITTED INFORMATION AS THEY ARISE. FOR CHANGES RESULTING FROM
ACTIONS THAT AROSE BETWEEN THE ANNUAL MEETINGS, THE CORPORATION SHALL SUBMIT ONLY THE AFFECTED PAGE OF THE GIS THAT RELATES
TO THE NEW INFORMATION TOGETHER WITH A COVER LETTER SIGNED BY THE CORPORATE SECRETARY OF THE CORPORATION. THE PAGE OF THE
GIS AND COVER LETTER SHALL BE SUBMITTED WITHIN SEVEN (7) DAYS AFTER SUCH CHANGE OCCURRED OR BECAME EFFECTIVE.

5 SUBMIT FOUR (4) COPIES OF THE GIS TO THE CENTRAL RECEIVING SECTION, GROUND FLOOR, SEC BLDG., EDSA, MANDALUYONG CITY. ALL COPIES
SHALL UNIFORMLY BE ON A4 OR LETTER-SIZED PAPER WITH A STANDARD COVER PAGE. THE PAGES OF ALL COPIES SHALL USE ONLY ONE SIDE.
CORPORATIONS SUBMITTING A COPY OF THEIR GIS ONLINE OR VIA INTERNET SHALL SUBMIT ONE (1) HARD COPY OF THE GIS, TOGETHER WITH A
CERTIFICATION UNDER OATH BY ITS CORPORATE SECRETARY THAT THE COPY SUBMITTED ONLINE CONTAINS THE EXACT DATA IN THE HARD COPY.

6 ONLY THE GIS ACCOMPLISHED IN ACCORDANCE WITH THESE INSTRUCTIONS SHALL BE CONSIDERED AS HAVING BEEN FILED.
7 THIS GIS MAY BE USED AS EVIDENCE AGAINST THE CORPORATION AND ITS RESPONSIBLE DIRECTORS/OFFICERS FOR ANY VIOLATION OF EXISTING
LAWS, RULES AND REGULATIONS
================================ PLEASE PRINT LEGIBLY =====================================

CORPORATE NAME: DATE REGISTERED:

BIOCARE WELLNESS CENTER INC.
10/2/2015
BUSINESS/TRADE NAME:
FISCAL YEAR END:
BIOCARE WELLNESS CENTER INC.
SEC REGISTRATION NUMBER:

CS201519967 December 31
DATE OF ANNUAL MEETING PER BY-LAWS: CORPORATE TAX IDENTIFICATION
NUMBER (TIN)

March 07 009-145-435-000
ACTUAL DATE OF ANNUAL MEETING: WEBSITE/URL ADDRESS:

2-Apr-20 N/A
COMPLETE PRINCIPAL OFFICE ADDRESS: E-MAIL ADDRESS:

U114-116 SPARK PLACE BLDG., P. TUAZON COR. 10TH AVE., CUBAO, QUEZON CITY [email protected]
COMPLETE BUSINESS ADDRESS: FAX NUMBER:

U114-116 SPARK PLACE BLDG., P. TUAZON COR. 10TH AVE., CUBAO, QUEZON CITY

NAME OF EXTERNAL AUDITOR & ITS SIGNING PARTNER: SEC ACCREDITATION NUMBER (if applicable): TELEPHONE NUMBER(S):

NORWEL DELA CRUZ LABOG

N/A 02-2814560

PRIMARY PURPOSE/ACTIVITY/INDUSTRY PRESENTLY ENGAGED IN: INDUSTRY CLASSIFICATION: GEOGRAPHICAL CODE:

PROVIDING HEALTH & SPA, ENHANCE FITNESS & HEALTH, IMPROVE WELL BEING N/A N/A

================================ INTERCOMPANY AFFILIATIONS =======================================

PARENT COMPANY SEC REGISTRATION NO. ADDRESS

SUBSIDIARY/AFFILIATE SEC REGISTRATION NO. ADDRESS

NOTE: USE ADDITIONAL SHEET IF NECESSARY

GIS_STOCK(v.2018) Page 1
GIS_STOCK(v.2018) Page 1
 GENERAL INFORMATION SHEET
STOCK CORPORATION
================================ PLEASE PRINT LEGIBLY ================================
Corporate Name: BIOCARE WELLNESS CENTER INC.
A. Is the Corporation a covered person under the Anti Money Laundering Act
(AMLA), as amended? (Rep. Acts. 9160/9164/10167/10365) Yes ● No
Please check the appropriate box:
1.
a. Banks
Jewelry dealers in precious metals, who, as a
b. Offshore Banking Units 4. business, trade in precious metals
c. Quasi-Banks
d. Trust Entities
e. Non-Stock Savings and Loan Associations
f. Pawnshops
g. Foreign Exchage Dealers Jewelry dealers in precious stones, who, as a
5. business, trade in precious stone
h. Money Changers
i. Remittance Agents
j. Electronic Money Issuers
k. Financial Institutions which Under Special Laws are subject to
Bangko Sentral ng Pilipinas' (BSP) supervision and/or regulation,
including their subsidiaries and affiliates. Company service providers which, as a business,
6. provide any of the following services to third
2 parties:
a. Insurance Companies
b. Insurance Agents a. acting as a formation agent of juridical persons
c. Insurance Brokers b. acting as (or arranging for another person to act as)
d. Professional Reinsurers a director or corporate secretary of a company, a
partner of a partnership, or a similar position in
e. Reinsurance Brokers relation to other juridical persons
f. Holding Companies
g. Holding Company Systems
h. Pre-need Companies c. providing a registered office, business address or
i. Mutual Benefit Association accommodation, correspondence or administrative
address for a company, a partnership or any other
j. All Other Persons and entities supervised and/or regulated by the legal person or arrangement
Insurance Commission (IC)
3
a. Securities Dealers d. acting as (or arranging for another person to act as)
b. Securities Brokers a nominee shareholder for another person
c. Securities Salesman
7. Persons who provide any of the following services:
d. Investment Houses a. managing of client money, securities or other assets
e. Investment Agents and Consultants
f. Trading Advisors b. management of bank, savings or securities accounts
g. Other entities managing Securities or rendering similar services
h. Mutual Funds or Open-end Investment Companies c. organization of contributions for the creation,
i. Close-end Investment Companies operation or management of companies
j. Common Trust Funds or Issuers and other similar entities
k. Transfer Companies and other similar entities d. creation, operation or management of juridical
l. Other entities administering or otherwise dealing in currency, persons or arrangements, and buying and selling
commodities or financial derivatives based there on business entities

m. Entities administering of otherwise dealing in valuable objects 8. None of the above

n. Entities administering or otherwise dealing in cash Substitutes and Describe
other similar monetary instruments or property supervised and/or nature of
regulated by the Securities and Exchange Commission (SEC) business:

B. Has the Corporation complied with the requirements on Customer Due Diligence
(CDD) or Know Your Customer (KYC), record-keeping, and submission of reports
under the AMLA, as amended, since the last filing of its GIS? Yes ● No

GIS_STOCK(v.2018) Page 2
 GENERAL INFORMATION SHEET
STOCK CORPORATION
==================================== PLEASE PRINT LEGIBLY ==================================
CORPORATE NAME: BIOCARE WELLNESS CENTER INC.

CAPITAL STRUCTURE
AUTHORIZED CAPITAL STOCK

NUMBER OF AMOUNT (PhP)

TYPE OF SHARES * PAR/STATED VALUE
SHARES (No. of shares X Par/Stated Value)

Common 10,000 500.00 5,000,000.00

TOTAL 10,000 TOTAL P 5,000,000.00

SUBSCRIBED CAPITAL

NUMBER OF
NO. OF
NUMBER OF SHARES IN THE PAR/STATED % OF
FILIPINO STOCK- TYPE OF SHARES * SHARES HANDS OF THE VALUE AMOUNT (PhP) OWNERSHIP
HOLDERS
PUBLIC **

5 Common 2,500 500.00 1,250,000.00

TOTAL 2,500 TOTAL TOTAL P 1,250,000.00

NUMBER OF
FOREIGN NO. OF
(INDICATE BY STOCK- NUMBER OF SHARES IN THE PAR/STATED % OF
TYPE OF SHARES * SHARES HANDS OF THE VALUE AMOUNT (PhP) OWNERSHIP
NATIONALITY) HOLDERS
PUBLIC **

Percentage of Foreign Equity : TOTAL TOTAL TOTAL P

TOTAL SUBSCRIBED P 1,250,000.00
PAID-UP CAPITAL
NO. OF NUMBER OF % OF
FILIPINO STOCK- TYPE OF SHARES * PAR/STATED VALUE AMOUNT (PhP)
SHARES OWNERSHIP
HOLDERS

5 Common 625 500.00 312,500.00 100.00

TOTAL 625 TOTAL P 312,500.00

FOREIGN NO. OF NUMBER OF % OF
(INDICATE BY STOCK- TYPE OF SHARES * SHARES PAR/STATED VALUE AMOUNT (PhP) OWNERSHIP
NATIONALITY) HOLDERS

0.00 % TOTAL TOTAL P

TOTAL PAID-UP P 312,500.00

NOTE: USE ADDITIONAL SHEET IF NECESSARY

* Common, Preferred or other classification
** Other than Directors, Officers, Shareholders owning 10% of outstanding shares.

GIS_STOCK (v.2018) Page 3

 GENERAL INFORMATION SHEET
STOCK CORPORATION
================================ PLEASE PRINT LEGIBLY ================================
CORPORATE NAME: BIOCARE WELLNESS CENTER INC.

DIRECTORS / OFFICERS
NAME/CURRENT RESIDENTIAL ADDRESS STOCK EXEC. TAX IDENTIFICATION
NATIONALITY INC'R BOARD GENDER HOLDER OFFICER COMM. NUMBER
1. VIVIAN L. SAAVEDRA
PRESIDEN
Ortigas Ave., Greenhills, San Juan FILIPINO Y C F Y T C 159-861-734
City
2 OSCAR B. SAAVEDRA
Y M M Y SECRETAR M 160-532-155
Ortigas Ave., Greenhills, San Juan FILIPINO Y
City
3 NICOLE L. SAAVEDRA
Y M F Y TREASURE M 714-372-926
Ortigas Ave., Greenhills, San Juan FILIPINO R
City
4 IVORY JOY T. MADRIAGA
91 Camiling Guimba, Nueva Ecija FILIPINO Y M F Y N/A N/A 410-212-275

5 MICHELLE JOY D. TAN

Gov. Ramos St., Brgy. Sta Maria., FILIPINO Y M F Y N/A N/A 470-986-317
Zamboanga City
6

10

11

12

13

14

15

INSTRUCTION:
FOR SEX COLUMN, PUT "F" FOR FEMALE, "M" FOR MALE.
FOR BOARD COLUMN, PUT "C" FOR CHAIRMAN, "M" FOR MEMBER, "I" FOR INDEPENDENT DIRECTOR.
FOR INC'R COLUMN, PUT "Y" IF AN INCORPORATOR, "N" IF NOT.
FOR STOCKHOLDER COLUMN, PUT "Y" IF A STOCKHOLDER, "N" IF NOT.
FOR OFFICER COLUMN, INDICATE PARTICULAR POSITION IF AN OFFICER, FROM VP UP INCLUDING THE POSITION OF THE TREASURER,
SECRETARY, COMPLIANCE OFFICER AND/OR ASSOCIATED PERSON.
FOR EXECUTIVE COMMITTEE, INDICATE "C" IF MEMBER OF THE COMPENSATION COMMITTEE; "A" FOR AUDIT COMMITTEE; "N" FOR NOMINATION
AND ELECTION COMMITTEE. ADDITIONALLY WRITE "C" AFTER SLASH IF CHAIRMAN AND "M" IF MEMBER.

GIS_STOCK (v.2018) Page 4

 GENERAL INFORMATION SHEET
STOCK CORPORATION
================================ PLEASE PRINT LEGIBLY ================================
CORPORATE NAME: BIOCARE WELLNESS CENTER INC.

TOTAL NUMBER OF STOCKHOLDERS: 5 NO. OF STOCKHOLDERS WITH 100 OR MORE SHARES EACH: 5

TOTAL ASSETS BASED ON LATEST AUDITED FINANCIAL STATEMENTS:

STOCKHOLDER'S INFORMATION

SHARES SUBSCRIBED
NAME, NATIONALITY AND CURRENT AMOUNT TAX IDENTIFICATION
RESIDENTIAL ADDRESS AMOUNT % OF PAID NUMBER
TYPE NUMBER
(PhP)
OWNER- (PhP)
SHIP

1 VIVIAN L. SAAVEDRA common 1,200 600,000.00

FILIPINO
Ortigas Ave., Greenhills, San Juan City 48.00% 150,000.00 159-861-734

TOTAL 1,200 600,000.00

2 OSCAR B. SAAVEDRA common 1,200 600,000.00

FILIPINO
48.00% 150,000.00 160-532-155
Ortigas Ave., Greenhills, San Juan City

TOTAL 1,200 600,000.00

3 NICOLE L. SAAVEDRA common 80 40,000.00

FILIPINO
3.20% 10,000.00 714-372-926
Ortigas Ave., Greenhills, San Juan City

TOTAL 80 40,000.00

4 IVORY JOY T. MADRIAGA common 10 5,000.00

FILIPINO
0.40% 1,250.00 410-212-275
91 Camiling Guimba, Nueva Ecija

TOTAL 10 5,000.00

5 MICHELLE JOY D. TAN common 10 5,000.00

FILIPINO
0.40% 1,250.00 470-986-317
Gov. Ramos St., Brgy. Sta Maria., Zamboanga
City
TOTAL 10 5,000.00

TOTAL
7

TOTAL

TOTAL AMOUNT OF SUBSCRIBED CAPITAL 1,250,000.00 100.00%

312,500.00
TOTAL AMOUNT OF PAID-UP CAPITAL

INSTRUCTION: SPECIFY THE TOP 20 STOCKHOLDERS AND INDICATE THE REST AS OTHERS
Note: For PDTC Nominee included in the list, please indicate further the beneficial owners owning more than 5% of any class of the company's voting
securities. Attach separate sheet, if necessary.

GIS_STOCK (v.2018) Page 5

 GENERAL INFORMATION SHEET
STOCK CORPORATION

==================================== PLEASE PRINT LEGIBLY ==================================

CORPORATE NAME: BIOCARE WELLNESS CENTER INC.

TOTAL NUMBER OF STOCKHOLDERS: 5 NO. OF STOCKHOLDERS WITH 100 OR MORE SHARES EACH: 5

TOTAL ASSETS BASED ON LATEST AUDITED FS:

STOCKHOLDER'S INFORMATION

SHARES SUBSCRIBED
TAX
NAME, NATIONALITY AND CURRENT AMOUNT PAID IDENTIFCATION
RESIDENTIAL ADDRESS TYPE NUMBER
AMOUNT % OF OWNER- (PhP)
(PhP) SHIP NUMBER

TOTAL

TOTAL

10

TOTAL

11

TOTAL

12

TOTAL

13

TOTAL

14

TOTAL

TOTAL AMOUNT OF SUBSCRIBED CAPITAL 0.00% 0.00

TOTAL AMOUNT OF PAID-UP CAPITAL

INSTRUCTION: SPECIFY THE TOP 20 STOCKHOLDERS AND INDICATE THE REST AS OTHERS
Note: For PDTC Nominee included in the list, please indicate further the beneficial owners owning more than 5% of any class of the company's voting securities. Attach
separate sheet, if necessary.

GIS_STOCK (v.2018) Page 6

 GENERAL INFORMATION SHEET
STOCK CORPORATION
==================================== PLEASE PRINT LEGIBLY ==================================

CORPORATE NAME: BIOCARE WELLNESS CENTER INC.

TOTAL NUMBER OF STOCKHOLDERS: 5 NO. OF STOCKHOLDERS WITH 100 OR MORE SHARES EACH: 5
TOTAL ASSETS BASED ON LATEST AUDITED FS:

STOCKHOLDER'S INFORMATION
SHARES SUBSCRIBED
NAME, NATIONALITY AND CURRENT AMOUNT PAID TAX IDENTIFICATION
AMOUNT % OF
RESIDENTIAL ADDRESS TYPE NUMBER OWNER- (PhP) NUMBER
(PhP) SHIP

15

TOTAL

16

TOTAL

17

TOTAL

18

TOTAL

19

TOTAL

20

TOTAL

21 OTHERS (Indicate the number of the remaining

stockholders)

TOTAL

TOTAL AMOUNT OF SUBSCRIBED CAPITAL 0.00%

0.00
TOTAL AMOUNT OF PAID-UP CAPITAL

INSTRUCTION: SPECIFY THE TOP 20 STOCKHOLDERS AND INDICATE THE REST AS OTHERS
Note: For PDTC Nominee included in the list, please indicate further the beneficial owners owning more than 5% of any class of the company's voting securities. Attach
separate sheet, if necessary.

GIS_STOCK (v.2018) Page 7

 GENERAL INFORMATION SHEET
STOCK CORPORATION
PLEASE PRINT LEGIBLY
CORPORATE NAME: BIOCARE WELLNESS CENTER INC.

1. INVESTMENT OF CORPORATE AMOUNT (PhP) DATE OF BOARD RESOLUTION

FUNDS IN ANOTHER CORPORATION
1.1 STOCKS
N/A
1.2 BONDS/COMMERCIAL PAPER (Issued
by Private Corporations) N/A

1.3 LOANS/ CREDITS/ ADVANCES

N/A
1.4 GOVERNMENT TREASURY BILLS
N/A
1.5 OTHERS
N/A
2. INVESTMENT OF CORPORATE FUNDS IN ACTIVITIES UNDER ITS DATE OF BOARD DATE OF
SECONDARY PURPOSES (PLEASE SPECIFY:) RESOLUTION STOCKHOLDERS
RATIFICATION

N/A

3. TREASURY SHARES
% AS TO THE TOTAL
NO. OF SHARES NO. OF SHARES ISSUED

N/A

4. UNRESTRICTED/UNAPPROPRIATED RETAINED EARNINGS AS OF END OF LAST FISCAL YEAR

5. DIVIDENDS DECLARED DURING THE IMMEDIATELY PRECEDING YEAR:
TYPE OF DIVIDEND AMOUNT (PhP) DATE DECLARED

5.1 CASH 0.00 N/A

5.2 STOCK 0.00 N/A
5.3 PROPERTY 0.00 N/A
TOTAL P
6. ADDITIONAL SHARES ISSUED DURING THE PERIOD:
DATE NO. OF SHARES AMOUNT

SECONDARY LICENSE/REGISTRATION WITH SEC AND OTHER GOV'T AGENCY:

NAME OF AGENCY: SEC BSP IC
TYPE OF
LICENSE/REGN. N/A N/A N/A

DATE ISSUED:

DATE STARTED
OPERATIONS:

TOTAL ANNUAL COMPENSATION OF

DIRECTORS DURING THE PRECEDING FISCAL TOTAL NO. OF OFFICERS TOTAL NO. OF RANK & TOTAL MANPOWER
YEAR (in PhP) FILE EMPLOYEES COMPLEMENT

3 2 5

NOTE: USE ADDITIONAL SHEET IF NECESSARY

GIS_STOCK (v.2018)

GIS_STOCK (v.2018) Page 8

 BENEFICIAL OWNERSHIP DECLARATION
A.      Natural person who ultimately owns or controls the corporation:
COMPLETE NAME SPECIFIC TAX
(Surname, Given Name, Middle Name, Name RESIDENTIAL NATIONALITY % OF OWNERSHIP IDENTIFICATION
Extension [i.e., Jr., Sr., III]) ADDRESS NO.
Ortigas Ave.,
SAAVEDRA, VIVIAN, LEE Greenhills, San FILIPINO 48.00% 159-861-734
Juan City

B.      Natural person who exercises ultimate effective control[1] over the corporation:
COMPLETE NAME (Surname, SPECIFIC TAX
Given Name, Middle Name, Name Extension RESIDENTIAL NATIONALITY % OF OWNERSHIP IDENTIFICATION
[i.e., Jr., Sr., III]) ADDRESS NO.
Ortigas Ave.,
SAAVEDRA, VIVIAN, LEE Greenhills, San FILIPINO 48.00% 159-861-734
Juan City

CORPORATE STOCKHOLDERS:[2]
ULTIMATE BENEFICIAL OWNER (3)
CORPORATE NAME COMPLETE NAME
TAX
AND (Surname, Given Name, SPECIFIC RESIDENTIAL NATIONALITY % OF IDENTIFICATION
BUSINESS/TRADE Middle Name, Name ADDRESS OWNERSHIP
NO.
NAME Extension[i.e., Jr., Sr., III])

OTHER STOCKHOLDERS:
A.       PARTNERSHIPS
ULTIMATE BENEFICIAL OWNER[4]
COMPLETE NAME
TAX
PARTNERSHIP (Surname, Given Name, SPECIFIC RESIDENTIAL
NATIONALITY
% OF
IDENTIFICATION
NAME Middle Name, Name ADDRESS OWNERSHIP
NO.
Extension[i.e., Jr., Sr., III])

B.       TRUSTS
ULTIMATE BENEFICIAL OWNER[5]
COMPLETE NAME TAX
(Surname, Given Name, SPECIFIC RESIDENTIAL % OF
NAME Middle Name, Name ADDRESS
NATIONALITY
OWNERSHIP
IDENTIFICATION
Extension[i.e., Jr., Sr., III]) NO.

1. Refer to the definition of ultimate effective control under Section 2.2. of SEC Memorandum Circular No. 17, series of 2018.
2. Indicate the intermediate layers of the company’s ownership structure, if any, in a separate sheet and attach an ownership chart clearly
showing the intermediate layers with their respective ownership amounts.
3. Refer to the definition of beneficial owner under Sections 2.1 and 2.2. of SEC Memorandum Circular No. 17, series of 2018.
4. Refers to the natural person who ultimately owns or controls the partnership or who exercises ultimate effective control over
the partnership.
5. Identity of the persons who control the trust and make the investment decisions; trust beneficiaries and the trustee; and individuals who furnish funds
into the trust.

GIS_STOCK(v.2018) Page 9
I, _____________OSCAR B. SAAVEDRA____________, Corporate Secretary of BIOCARE WELLNESS CENTER
INC., declare under penalty of perjury that all matters set forth in this GIS have been duly verified by
me and to the best of my knowledge and belief are true and correct.

By indicating herein the personal information of the incorporators, stockholders, directors, officers,
beneficial owners, external auditor, notary public and their agents, I attest that the aforementioned
persons authorize the SEC to: (1) collect, process and store their personal information through the GIS
forms and related documents, for the period allowed under the applicable laws and regulations; and
(2) share with and make available the GIS to interested parties in order to pursue lawful purposes and
legitimate interests, and comply with legal mandate.

I also attest that the company and the aforementioned persons authorized the undersigned to file this
GIS with SEC, and the information provided herein are true, accurate, timely and complete.

I further attest that they are aware of their rights under the Data Privacy Act, including the right to be
informed, to access, to object, to erasure or blocking, to damages, to file a complaint, to rectify and to
data portability, and understand that there are procedures, conditions and exceptions to be complied
with in order to exercise or invoke such rights.

I likewise understand that the failure of the corporation to file this GIS for five (5) consecutive years
shall be construed as non-operation of the corporation and a ground for the revocation of the
corporations’ certificate of incorporation in this eventuality, the corporation hereby waives its right to
hearing for the said revocation.

Done this _______ day of ________________, 20 _____ in _____________________________.

____________________________________________
(Signature over printed name)

SUBSCRIBED AND SWORN TO before me in _______________________ on ____________________ by affiant who

personally appeared before me and exhibited to me his/her competent evidence of identity consisting
of _____________________ issued at ____________ on ___________________.

NOTARY PUBLIC

GIS_STOCK (v.2018) Page 10