HomeMy WebLinkAboutScanned on 04/05/2017 at 15:20:01 ' ATTACHWNT D
TOWN OF SOUTH WINDSOR,CONNECTICUT
' PROPOSER.'S LEGAL STATUS DISCLOSURE
Please (ally complete the applicable section below, attaching a separate sheet if you need
additional space.
For pu poses of this diselnSquIre, `nerrw ePt p1_ace of ir+i,sinplss" niPans an office c ntipwousiv
' maintained, occupied and used by the proposer's regular employees regularly in attendance to
carry on the proposer's business in the proposer's own name. An office maintained, occupied
and used by a proposer only for the duration of a contract will not be considered a permanent
' place of business. An office maintained, occupied and used by a person affiliated with a
proposer will not be considered a permanent place of business of the proposer.
' IF A SOLELY OWNED BUSINESS:
Proposer's Full Legal Name
Street Address
Mailing Address(if different from Street Address)
' Owner's bull Legal Name
Number of years engaged in business under sole proprietor or trade name
' Roes the proposer have a`permanent place of business"in Connecticut, as defined above?
Yes No
' If yes,please state the full street address(not a post office box)of that"permanent place
of business"
' IF A CORPORATION:
' Proposer's Full legal Name
Street Address
Mailing Address(if different from Street Address)
Owner's Full Legal Name
' Number of years engaged in business
Names of Current Officers
' President Secretary Chief Financial Officer
' Does the proposer have a"permanent place of business"in Connecticut,as defined above?
Yes No
If yes,please state the full street address (not a post office box)of that"permanent place
of business."
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IF A ILINHTED LIABILITY COMPANY;
' Proposer's Full legal Name TaxSery Capital Services, LLC
Street Address 210 Oak St, Suite 310, Hartford, CT 06106
Mailing Address(if different from Street Address)
Owner's Full Legal Name Daniel T. Ku s i c
' Number of years engaged in business 2 3
Names of Current Manager(s)and Member(s)
' TaxServ, LLC 1313 Dolley Madison Blvd, Ste LL-130, McLean VA 22101
Name&Title(if any) Residential Address(street only)
Rumson Holdings Inc . 1454 Hampton Hills Circle, McLean VA 22101
Name&Title(if any) Residential Address(street only)
' Daniel T. Kusic 1454 Hampton Hills Circle, McLean VA 22101
Name&Title(if arty) Residential Address (street only)
' Name&Title(if any) Residential Address(street only)
' Name&Title(if any) Residential Address(street only)
Does the proposer have a"permanent place of business"in Connecticut,as defined above?
' X Yes No
If yes,please state the full street address (not a post office box)of that"permanent place
of business."
210 Oak St, Suite 310, Hartford, CT 06106
' IF A PARTNERSHIP
Proposer's Full Legal Name
' Street Address
Mailing Address(if different from Street Address)
' Owner's Full Legal Name
Number of years engaged in business
' Names of Current Partners
' Name&Title(if any) Residential Address(street only)
Name&Title(if any) Residential Address(street only)
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' Name&Title(if any) Residential Address(street only)
Does the proposer have a"permanent place of business"in Connecticut,as defined above?
' Yes No
If yes,please state the full street address (not a post office box)of that"permanent place
of business."
TaxS,ery Capital Services, LLC
-...............
_...__.,...�
Proposer's Full Legal Name
Roger Blain - President
(print)
NameA� e of . e r's Authorized Representative er��--
' (signature)1
Proposer's Representative,Duly Authorized
' September 27, 2016
Date
' LEND OF LEGAL STATUS DISCLOSURE FORM
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