E—Namt Megi( 453ociot 4Ae, Employer Street Address: 615- LeAg;v14, A.! 4veilve city a leut/ y oe k *Signakre reeWred below "If you do not have a Social Security Number. please submit a photocopy of you passport and a copy of a bank or brokerage statement. 9 Th Root Occupation/Type of Business: (37) State: Ai tv