State of California Department of Alcoholic Beverage Control ALIEN VERIFICATION ACKNOWLEDGMENT Instructions: This form must be signed by any sole owner applicant who provides an alien verification document with an expiration date. APPLICANT'S ACKNOWLEDGMENT As part of my application for an alcoholic beverage license, I gave the Department of Alcoholic Beverage Control (ABC) an alien verification document to establish my eligibility for State benefits (i.e.,an ABC license). The document that I provided to ABC will expire on . I understand the following: (1) If ABC approves my license application, it will issue an alcoholic beverage license to me that will expire on . If I receive an ABC license, in order for me to continue to sell alcoholic beverages beyond , I must provide ABC with documentation, which supports legal presence beyond that date. No later than (a) (b) I must submit the following to ABC Headquarters: A completed Form ABC-69, [Statement of Citizenship, Alienage, ] and Immigration Status for State Public Benefits; and A photocopy of both sides of one of the documents listed on the ABC-69, Section A or B extending my eligibility. (Send items (a) and (b) to ABC Headquarters, Attention: Alien Verification Unit, 3927 Lenanne Drive, Suite 100, Sacramento, CA 95834.) (4) MY FAILURE TO PROVIDE ITEMS (a) and (b) ABOVE WILL RESULT IN THE REVOCATION OF MY ABC LICENSE AND THE LOSS OF ALL ABC FEES I HAVE PAID. DATE SIGNED (2) (3) APPLICANT'S SIGNATURE APPLICANT'S PRINTED NAME DAYTIME TELEPHONE NUMBER ( SIGNATURE OF PERSON ACTING FOR APPLICANT ) DATE SIGNED PRINTED NAME OF PERSON ACTING FOR APPLICANT DAYTIME TELEPHONE NUMBER ( ABC-69-A (12/13) ) American LegalNet, Inc. www.FormsWorkFlow.com