www.com.ohio.gov/documents/liqrFingerPrint.pdf. CEO PresidentVice-PresidentSecretaryTreasurer/CFOSECTION B.write "NONE")Shareholders holding 5% or more of outstanding shares. If you answered question 1 YES in Section B, do not completeAddressNameNUMBER OF SHARES HELD (NOT PERCENTAGE) LIQ-18-0014 - DLC 4030 Please be advised that any social security numbers provided to the Division of Liquor Control may be released to the Ohio Department of Public Safety, the Ohio Department of Taxation, the Ohio Attorney General, or to any other state or local law enforcement agency if the agency requests the social security number to conduct an investigation, implement enforcement action, or collect taxes.BB YES NO YES NO OT complete Section D. (Position) (Date)(eSignature - Electronic Signature)(Address)(City)(State)(Zip Code)(Telephone Number) CERTIFICATION OF FORM:By signing below, I certify that I have authority to execute this document and the information provided is true, correct andcomplete to the best of my knowledge and belief.NUMBER OF SHARES HELD (NOT PERCENTAGE)Address Fax 614 | 644 3166 TTY/TDD 800 | 750 0750 www.com.ohio.govAn Equal Opportunity Employer and Service Provider6606 Tussing RoadPO Box 4005Reynoldsburg, OH 43068-9005 U.S.A. 614 | 644 2360Revised 5/13/2019The Background check process can be found at American LegalNet, Inc. www.FormsWorkFlow.com Page 2DLC 4030 (OFFICER / SHAREHOLDER DISCLOSURE FORM)SECTION D (CONTINUED)Individuals listed below must have a background check performed by BCI and submit a Personal History Background Form. "NONE": 3AddressNUMBER OF SHARES HELD (NOT PERCENTAGE)4AddressNUMBER OF SHARES HELD (NOT PERCENTAGE)5AddressNUMBER OF SHARES HELD (NOT PERCENTAGE)6AddressNUMBER OF SHARES HELD (NOT PERCENTAGE)7AddressNUMBER OF SHARES HELD (NOT PERCENTAGE)8AddressNUMBER OF SHARES HELD (NOT PERCENTAGE)0AddressNUMBER OF SHARES HELD (NOT PERCENTAGE)9AddressNUMBER OF SHARES HELD (NOT PERCENTAGE)LIQ-18-0014 - DLC 4030The Background check process can be found at www.com.ohio.gov/documents/liqrFingerPrint.pdf. American LegalNet, Inc. www.FormsWorkFlow.com