164-22 Exhibits to Agreement for Workers Compensation Third Party Administration - 2022.pdf

: STOCKHOLDER DISCLOSURE CERTIFICATION T certify that the list below contains the names and home addresses of all stockholders holding 10% or more of the issued and outstanding stock of the undersigned, I certify that no one stockholder owns 10% or more of the issued and outstanding stock of the undersigned. PLEASE COCK TYPE OF BUSINESS ORGANIZATION: Partnership Limited Partnership. Limited Liability Corp Corporation _X Sole Proprietorship Limited Liability Partnership Subchapter § Corp PLEASE CHECK APPROPRIATE BOXES AND SIGN BELOW aa Name: David Harris Home Address: 2295 Gulf of Mexico Drive, Longboat Key FL 34228 Stockholders i Name: _CRC-NJ Midco, Inc. Home Address: 2100 Ponce de Leon Blvd, Suite 730 Coral Gables FL 33134 Name_CRC-NJ Holding Corp. _ Home Address: 2100 Ponce de Leon Blvd, Suite 730 _ Coral Gables FL 33134 Name: _CRC-NJ Investors, LLC. Home Address: 2100 Ponce de Leon Blvd, Suite 730 hy Coral Gables FL 33484 x David Harris, President Print Name & Title NOTORY PUBLIC Swom before me this {2 day of May a a wily LAUREN F WALTER Notary Public - State of New Jersey My Commission Expires Aug 30, 2023