Illinois Liquor Control Commission Pat Quinn Governor CHANGE OF CORPORATE OFFICERS If you are ONLY changing corporate officers, you can simply update your ownership information along with the supporting documents listed below. NOTE: Your Illinois Business Tax (IBT) no., Federal Employer Identification No. (FEIN), and LLC/Corporate/Partnership name MUST remain unchanged to use this form. Please send this form and supporting documents to: ILCC Licensing, 100 W. Randolph, Ste. 7-801, Chicago, IL 60601 (FAX: 312-814-2241). The Illinois Liquor Commission requires proof of officer changes [235 ILCS 5/7-1 (24)]. We will not make any officer changes without supporting documentation. The information listed below MUST be submitted prior to any officer changes being made: 1. Proof of approval from the locality supporting the change of officers. Providing us with a copy of your local license does not qualify as approval for officer changes UNLESS the local license reflects the individual names of the corporate officers on the local license. If the local license does not reflect the individual names of all corporate officers then you will need to provide us with a letter from the local municipality verifying that they are aware of the officer change and have approved the change of officers. This letter should reflect the names of officers that are being added or deleted. 2. Evidence of transfer—this can be in the form of any of the documents listed below: a. Stock Purchase Agreement; b. Bill of Sale; c. Filed Change of Officer application from the Secretary of State. 3. Applicants must update their officer/ownership information with the Illinois Department of Revenue by calling the Central Registration Division in Springfield at 800-732-8866 or 217-782-3336. NEW OWNERSHIP INFORMATION A. NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. B. DATE OF BIRTH DATE OF BIRTH SEX AREA CODE/TELEPHONE NO. CITY TITLE/POSITION AREA CODE/TELEPHONE NO. CITY TITLE/POSITION AREA CODE/TELEPHONE NO. HOME ADDRESS SEX TITLE/POSITION HOME ADDRESS SEX NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. E. DATE OF BIRTH CITY HOME ADDRESS SEX NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. D. HOME ADDRESS NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. C. DATE OF BIRTH STATE LIQUOR LICENSE NUMBER: CITY TITLE/POSITION AREA CODE/TELEPHONE NO. TOTAL PERCENTAGE OF ALL STOCK HELD BY ALL PERSONS WITH LESS THAN 5% INTEREST STATE STATE STATE STATE ZIP % OWNED ZIP % OWNED ZIP % OWNED ZIP % OWNED % American LegalNet, Inc. www.FormsWorkFlow.com