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*Name of the LLC:

*Name and Address of Manager of LLC:

*Business Address for LLC (NO PO BOXES):

*Who is your IRA Custodian (N/A if none IRA):

*Name of IRA Account Holder (N/A if none IRA):

*Name and Address of Statutory Agent (NO PO BOXES):

Please provide SS# for LLC tax ID#:

*Your Primary Phone Number:

*Your Email Address:

*Who referred you to Easy IRA LLC?:

Any additional comments:

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* Boxes are required.