ARIZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL 400 W Congress #521 Tucson AZ 85701-1352 (520) 628-6595 800 W Washington 5th Floor Phoenix AZ 85007-2934 (602) 542-5141 INACTIVE/ACTIVE STATUS FORM Pursuant to A.R.S. Section 4-203 (G) PRINT AND USE BLACK INK ONLY INACTIVE STATUS (Complete Questions 1, 2, 3, 4, 5, 6, 7) ACTIVATING LICENSE (Complete Questions 1, 2, 3, 4, 5, 8,) CHECK ONE BOX ONLY: 1. License Number: 2. Licensee/Agent's Name: Last First Street Middle City 3. Business Name: 4. Business Address: 5. Date license was last used: State Zip Date license went on Inactive Status: 6. License is not being used because: 7. Future plans to place the license in use: 8. Date you intend to place license back in use: FALSE OR INCOMPLETE ANSWERS COULD RESULT IN CRIMINAL PROSECUTION AND THE DENIAL, OR SUBSEQUENT REVOCATION OF A LICENSE OR PERMIT. ════════════════════════════════════════════════════════════════════════════════ I, , hereby declare that I am the AUTHORIZED PERSON (Print full name) filing this notification. I have read this document and the contents and all statements are true, correct and complete. State of County of The foregoing instrument was acknowledged before me this X (Signature) Day Month Year My commission expires on: (Signature of NOTARY PUBLIC) *Disabled individuals requiring special accommodations, please call the Department.542-9027 LIC0110 05/2004 American LegalNet, Inc. www.FormsWorkflow.com A.R.S. Section 4-203 (G) provides: A licensee who holds a license in nonuse status more than five months shall be required to pay a one-hundred dollar surcharge for each month thereafter. The surcharge shall be paid at the time the license is returned to active status. A license automatically reverts to the state after being held in continuous nonuse in excess of thirty-six months. Also, A.R.S. Section 4-203(O) states: If a licensed location has not been in use for two years, the location must re-qualify for a license..... (In other words, if your license has been in nonuse for over two years, you lose the location and must reapply.) If you are NOT using your liquor license, complete an INACTIVE STATUS FORM and submit it to the Department's Licensing Division. Your license can remain on inactive status for FIVE months before an assessment of $100.00 per month thereafter begins accumulating. If you activate the license WITHOUT notifying the Department, you may be assessed the surcharges. Therefore, it is important that you notify the Department on an ACTIVE STATUS FORM promptly. Failure to notify the Department of either Inactive or Activating Status may result in revocation as stated in A.R.S. 4-203(N): Failure to pay any surcharge .... or failure to report the period of nonuse of a license shall be grounds for revocation of the license .... Your license MUST be renewed when it is in nonuse status. Renewal of your license does NOT place it into use or nonuse. You must use the Department's forms or a personal written request. American LegalNet, Inc. www.FormsWorkflow.com