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ease Dint deany) Federal Idendreation Number: iiarre: b I BLUE CHIP CAPITAL LLC C2 (c) Femurs Slate of Parldenm or Communal Domicil° c1 FL (d) Indiana Tax WitWleid for Nonrcsidert Partner (on W11-18) d .00 (e) Partnere Federal Pro Nan Percentage 3.60018.0 (0 Partner's Tax as Computed on I1.65CO
d Credits North Carolina Department of Revenue 2 012 or hscal year boptnnind Partner's Identifying Number Partner's Name, Address, and ZIP Code BLUE CHIP CAPITAL LLC 329 SEABREEZE AVENUE PALM BEACH FL 33480 and ending Federal Employer ID Number Pi dnership's Name, Address, and ZIP Cods SV AMERICA HOLDINGS LL
, vial the DepalmenEs website at wortin.gov/dor/3172.htm Pro rata amounts for lines 1 tnrobgh 26 of any nonresident partner must be mulipried by the Indiana apportionment percent, if applicable. from IT-65, Fne 4. Part I - Partner's Ideal flcadon Section (a) If Partner Is an Individual (please print cle
curity Nanber: Last Name: Fket Name: al a2 a3 (o) If Partner Is an Ober Entity (abase orbit clearly) Federal Identification Number, Name: 51 BLUE CHIP CAPITAL LLC b2 (c) Partner's Stale of P.asIdenoe or Commercial Do,Meie cl FL (d) Ind9na lax WIthhed for Nonresident Partner (on WH-I8). _ d .00 (e
visit the Deoartmenrs webs?* at vmw.in.govidor/3772.htm Pro rate amounts for lines 1 through 28 of any nonresident partner must be multiplied by the Indiana apportionment oe-cent, if applicable, from IT-85, line 4. Part 1 - Partner's Identification Section (a) If Partner Is an Individual (please print
's LrJoitc.:y truirc, palnerstip (P- P• ik—Abornesktma E Partners inernfylna number 20-3161309 F Penners num address. city. Matt and 2IP code BLUE CHIP CAPITAL LLC 27 HIGH TECH BLVD. THOMASVILLE, NC 27380 O n General oarlfief r lC E Limited partneror otter LLC tnertbrr-rnanast neater H RI Domed: Penny
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