AFFIDAVIT FOR CHANGE OF LIMITED LIABILITY COMPANY (LCC) MEMBER FOR SHIPPERS 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN, NE 68509-5046 PHONE: (402) 471-2571 FAX: (402) 471-2814 Website: www.lcc.ne.gov/ LIMITED LIABILITY COMPANY INFORMATION Limited Liability Company Name Limited Liability Company Liquor License Number Limited Liability Company Address City State Zip Code Limited Liability Company Contact Name Contact Telephone Number LIMITED LIABILITY COMPANY MEMBERS after completion of this LLC change, members will be as follows: Name: (Last, First, Middle) MEMBER Home Address: (Street) City, State, Zip Code Telephone Number Percentage of membership Name: (Last, First, Middle) MEMBER Home Address: (Street) City, State, Zip Code Telephone Number Percentage of membership Name: (Last, First, Middle) MEMBER Home Address: (Street) City, State, Zip Code Telephone Number Percentage of membership 1 Form 139 Rev 4/2014 American LegalNet, Inc. www.FormsWorkFlow.com Certification by Limited Liability Company Contact Under penalty of perjury, I hereby certify that each member is the real party in interest with respect to his/her position and is not acting directly or indirectly as agent, employee or representative of any other person not reported. The undersigned certifies on behalf of the LLC that it is understood that a misrepresentation of fact is cause for rejection of this application or suspension, cancellation or revocation of any license issued. __________________________________________________________________ __________________________ Print Name Title _________________________________________________________________ ___________________________ Signature Date 2 Form 139 Rev 4/2014 American LegalNet, Inc. www.FormsWorkFlow.com