PLCB-1898A 9/13 COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD TAX CERTIFICATION STATEMENT FOR MANAGEMENT COMPANY (SEE INSTRUCTIONS ON REVERSE) BUREAU OF LICENSING AcompletedTaxCertificationStatementmustbefiledforamanagementcompany,asrequiredbySection477ofthe LiquorCode.Failuretoprovidetherequestedinformationand/oranyoutstandingstateincome,corporation,limitedliability company, limited liability partnership, sales or unemployment compensation tax obligations (including failure to file or register)willcausethelicenseapplicationtoberejected.Ifadditionalspaceisneeded,pleaseusewhite8½"x11"paper. Type or print all information requested. 1. LICENSEE (APPLICANT) NAME 2. BUSINESS PHONE NO. AREA CODE 3. TRADE/FICTITIOUS NAME (IF ANY) 4. LICENSED ADDRESS (STREET, RURUAL ROUTE, P.O. BOX NO.) (POST OFFICE) (STATE) (ZIP) 5. TYPE OF APPLICATION FILED NEW TRANSFER OTHER IF A TRANSFER BUYER SELLER 6. LCB LICENSE NUMBER (IF NONE, CHECK HERE ) 7. 8. NAME OF MANAGEMENT COMPANY TYPE OF ENTITY SOLE PROPRIETOR LIMITED LIABILITY COMPANY PARTNERSHIP CORPORATION LIMITED LIABILITY PARTNERSHIP CLUB 9. LIST LICENSEE NAME (PRINT) SOCIAL SECURITY NUMBER COMPLETE ALL BLOCKS 10. LIST THE FOLLOWING STATE TAX IDENTIFICATION NUMBERS (ALL ITEMS: A,B,C, AND D MUST BE COMPLETED). A. SALES TAX LICENSE (8 DIGITS) N/A C. CORPORATE BOX/BUSINESS PARTNER NUMBER N/A B. EMPLOYER ID (EIN) (9 DIGITS) N/A D. UNEMPLOYMENT COMPENSATION ACCOUNT NUMBER N/A 11. 12. If you currently have a License, do you have employees or have you employed anyemployeessinceyoufiledyourlastrenewalapplication? YES NO AFFIRMATION:Iswearoraffirm,subjecttothepenaltiesprovidedby18Pa.C.S.§4904, and 47 P.S. §403(h)and/or4-436(j) and/or §7-704,thatallinformationrequiredhereinhasbeenprovided,andwithrespecttoallStatetaxestowhichapplicant mangementcompanyissubject,alltaxreportshavebeenfiled,and allStatetaxeshavebeenpaid,oraresubjecttoatimely administrativeorjudicialappeal,oraresubjecttoadulyapproveddeferredpaymentplan. SIGNATURE TITLE DATE American LegalNet, Inc. www.FormsWorkFlow.com SECTION 477 OF THE LIQUOR CODE REQUIRES THE BOARD NOT TO APPROVE ANY APPLICATION FOR A GRANT OR RENEWAL OR TRANSFER OF A LICENSE WHERE THE MANAGEMENT COMPANY CONTRACTED BY THE LICENSEE OR APPLICANT FOR PLCB LICENSE HAS FAILED TO PROVIDE ANY OF THE INFORMATION REQUIRED (ON THE REVERSE), OR HAS FAILED TO FILE REQUIRED STATE TAX REPORTS OR TO PAY CERTAIN STATE TAXES. IF A TRANSFER APPLICATION, THE TERM "APPLICANT" INCLUDES ANY MANAGEMENT COMPANY CONTRACTED BY EITHER THE TRANSFEROR AND TRANSFEREE. ALL MANAGEMENT COMPANIES ARE REQUIRED TO FILE THE TAX CERTIFICATION STATEMENT. - INSTRUCTIONS EACH AND EVERY ITEM MUST HAVE AN ENTRY!! PRINT OR TYPE ALL INFORMATION REQUESTED 1. LICENSEE NAME: List full exact name as it now appears on license if you are filing this with a transfer of the license.Ifyouareanewapplicantforlicense,oratransfereeofanexistinglicense,listtheownershipname,i.e., sole proprietor, corporation, etc. 2. BUSINESS PHONE: Includeareacodeinthenumber. 3. TRADE/FICTITIOUS NAME (if any):Ifyouareanewlicenseapplicantoratransferororatransfereeofanexisting license,listyourfullexacttradenameorregisteredfictitiousnameasshownonyourapplication.Donotlistafictitious nameunlessitisregisteredwiththePennsylvaniaDepartmentofState. 4. LICENSED ADDRESS, ETC.: Ifyouareanewapplicantforlicense,oratransfereeofanexistinglicense,listfull exactaddressofproposedpremisesasshownonyourapplication. 5. TYPE OF APPLICATION FILED: (Self-explanatory). 6. LCB LICENSE NUMBER (If "none," so state): Ifthisisbeingfiledwithtransferrefertocurrentlicense;NUMBER IS ABOVE NAME AT TOP LEFT OF LICENSE. Ifnewapplicant,insert"NONE. 7. LIST THE NAME OF THE MANAGEMENT COMPANY. 8. TYPE OF ENTITY: For management company. 9. LIST LICENSEE: If management company is sole proprietor. Note Names entered MUST have a Social Security number. 10. LIST TAX ID/ACCOUNT NUMBERS FOR MANAGEMENT COMPANY: Thesenumber(s)areshownontherespective licenses/permitsissuedbythePennsylvaniaDepartmentofRevenueoronQuarterlyTaxFormUC-2issuedbythe PennsylvaniaDepartmentofLaborandIndustry.Registeringandelectronicfilingofreturnsandpaymentinformation canbefoundbyvisitingPADepartmentofRevenuewebsite(www.revenue.state.pa.us). 10A.SalesTaxNumberisissuedbythePennsylvaniaDepartmentofRevenue,SalesTaxDivision. 10B.EINTaxNumberisissuedbytheFederalGovernment.NOTE:Ifyoudonothavethisnumber,youshouldcontact theFederalGovernmenttosecureanumberandthenregisterthisnumberwiththePennsylvaniaDepartment ofRevenue,EmployerWithholdingDivision.IfyouhaveanEINnumberbutnoemployees,pleaseindicateby checkingtheN/Abox. 10C.TheCorporateBoxOrBusinessPartnerNumberisissuedbythePennsylvaniaDepartmentofRevenue,Bureau ofCorporationTaxes. 10D.TheUnemploymentCompensationAccountNumberisissuedbythePennsylvaniaDepartmentofLaborand Industry,BureauofEmployerTaxOperations. ALL fouritems(A,B,C,andD)underQuestionNo.10mustbecompletedwithanumber,orbycheckingeitherthe block"N/A" whichmeans"NOT APPLICABLE." AnytaxIDlinethatisblankwillcauseadelayintheprocessingof your license application. 11. (Self-explanatory) 12. AFFIRMATION: Becertaintoaffixyoursignature,titleanddate.ItisrequiredthattheTaxCertificationStatement besignedbytheproprietor,partner,orresponsiblecorporateofficer. A THOROUGH ITEM BY ITEM REVIEW OF THIS FORM SHOULD BE MADE PRIOR TO SIGNING AND PLACING IN THE MAIL. FAILURE TO ANSWER ALL QUESTIONS COMPLETELY ON THIS FORM WILL CAUSE YOUR LICENSE APPLICATION TO BE REJECTED. American LegalNet, Inc. www.FormsWorkFlow.com