Description

Mandatory beneficial ownership reporting form five 5510 Make CHECK or MONEY ORDER payable to: Annual Records Service. Reporting Entity ACCESS CULTURE INC. 3 SUMMIT RD MEDFORD, MA 02155-3010 T#2 PURSUANT TO THE UNITED STATES ENACTED BY CONGRESS. US Businesses are required to report their beneficial /nership information. A reporting company is any corporation, limited liabity comp , or any other entities created by the filing of a document with a secreta ry of state any similar office in the United States. A beneficial owner is an individual who either directly or indirectly: (1) exercises substantial contrd over the reporting company (President, CEO, COO, CFO, etc.), or (2) owns or controls at least 25% of the reporting company's ownership interests. EXEMPT ENTITIES: Inactive Entity, Dissoved Entity, 501(c)3 Nan Profit. PENALTIES FOR NON COMPLIANCE: Companies who willfully provide false information or neglect lo report by the filing deadline can face a civil penalties of up to $500 for each day that the vidation continues or has no been remedied. In addition, they can be fined up to $10,000 and/or face up to 2 years of imprisonment. Employment Identification Number (EIN) Titie (Select One) ? o w e r • Officer Paid Preparer Reporting Entity Type o r Print Submitter Full Name Submitter Phone Number Submitter E mail P a r t | B e n e fi c i a l Owners Beneficial Owner Number 1 - First Name Middle Initial Address City State Beneficlal Owner Number 2 - First Name (If None Leave Blank) M i d d l e Initial Address City S t a t e Beneficial Owner Number 3 - First Name (11 None Leave Blank) Middlo Inital A d d r e s s City State Beneficial Owner Number 4 - First Name (1f None Leave Blank) | Middie Initial A d d r e s s City State P a r t I l S i g n a t u r e a n d P a y m e n t Sumbitter Signature Last Name Unit, Suite, Room, Etc. Zip Code Last Name Unit, Suite, Room, Etc. Zip Code Last Name Unit, Suite. Room, Etc Zip Code Last Name Unit, Suite, Room, Etc. Zip Code Date (MM/DD/YYYY) MAKE CHECK OR MONEY ORDER PAYABLE TO: Annual Records Service Filing Fee $119 For Internal Use Only KC: EID: Date: Annual Records Service to act as your paid preparer to file this BOl on your behall Annual Records Service Form 4022 (Rev. January 2024)