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 STATEMENT OF LEGAL OR EQUITABLE INTEREST (This form does not create a lien) NOTE: THIS DOCUMENT MUST BE SIGNED BY BOTH PARTIES. THE FILING OF THIS FORM WITH THE DEPARTMENT OF LIQUOR DOES NOT CREATE A LIEN. THIS FORM IS FOR NOTIFICATION PURPOSES ONLY. INTEREST HOLDER DATA: Interest Holder's Name: Last First Middle Address City State Mailing Address: Business Phone: ( Residence Phone: ( ) Zip ) The licensee, or prospective licensee, hereby grants to the above-named interest holder, a legal and/or equitable interest in the designated spirituous liquor license, pursuant to and in accordance with that certain (Describe document that generated this interest, i.e. security agreement, etc.) hereinafter called Collateral Agreement, between the licensee and the interest holder said is dated: Day Month Year and which Collateral Agreement is incorporated herein by reference. An executed copy of the Collateral Agreement will be located and available for inspection and reproduction at (Insert business name and address where Collateral Agreement is located) This statement is filed in accordance with A.R.S. 4-112.B(3) and A.A.C. R19-1-302. The statement of legal or equitable interest shall allow the person filing said statement to participate in the proceedings and shall not in any manner bind the Director or the State Liquor Board concerning the matter under consideration. The parties acknowledge and agree that all notices will be made with the parties at the addresses shown herein above, unless same are changed in writing and delivered to the Department of Liquor Licenses and Control. X (Signature of INTEREST HOLDER) State of County of The foregoing instrument was acknowledged before me this day of Day Month Year My commission expires on: (Signature of NOTARY PUBLIC) LICENSEE DATA: Licensee/Applicant's Name: (Exactly as it appears on license/application) Last First Middle Address City State Zip Address City State Zip Mailing Address: License Location: (Exactly as it appears on the license) License Number: Phone Number: ( State of X ) County of The foregoing instrument was acknowledged before me this (Signature of LICENSEE/APPLICANT) day of Day , Month Year My commission expires on: (Signature of NOTARY PUBLIC) LIC 0104 08/2006 *Disabled individuals requiring special accommodations, please call (602) 542-9027. American LegalNet, Inc. www.FormsWorkflow.com A.A.C. R19-1-302 FILING OF LEGAL OR EQUITABLE INTEREST A. In accordance with A.R.S. Section 4-112.B.3, all persons having a legal or equitable interest in a spirituous liquor license shall file with the director a statement of such interest on a form prescribed and furnished by the department. Notice of termination of such interest shall be filed in writing by the interest holder upon final determination of the interest. Interest holders shall immediately file amended statements to reflect any change in the current statements presently on file. B. The director may periodically, by notice to the holders of interests filed under this rule and under A.R.S. Section 4-112.B.3, require such interest holders to verify in writing to the director that the statement presently on file is currently correct and accurate and, if not, such interest holder shall immediately file an amended statement or termination notice. If no response is received by the director within thirty (30) days of the mailing of such notice, the interest shall be deemed terminated. C. All persons having filed statements of interest in accordance with this rule and the statute shall be given notice of all matters and/or actions affecting or regarding the spirituous liquor license in which they have an interest. D. Notice as required in C above shall be fully effective by mailing a copy thereof by registered or certified mail in a sealed envelope with postage prepaid and addressed to such person at his address as shown by the statement on file with the director. Service of such notice shall be complete when deposited in the U.S. Mail. E. All interest holders who are entitled to receive notice as provided for herein above shall have the right to appear and participate in person and through counsel in any hearing held before the board or director affecting the subject spirituous liquor license as his interests may appear. F. The statement of legal or equitable interest shall allow the person filing said statement to participate in the proceedings and shall not in any manner bind the director or the State Liquor Board concerning the matter under consideration. American LegalNet, Inc. www.FormsWorkflow.com