State of California Department of Alcoholic Beverage Control CERTIFICATION RE CHAPTER 15 TIED-HOUSE RESTRICTIONS Instructions · Type or print clearly in black or blue ink (do not use red). · This form is to be completed by all applicants, retail and non- retail. · This form is used to ensure compliance with tied-house laws, which generally prohibit or restrict vertical integration. These laws prohibit vertical integration of the three levels of the alcoholic beverage industry (manufacturer, wholesaler, and retailer). (Section 25500, et seq., Business & Professions Code.) License Applicant Name (Item 1) -- Enter the name of the license applicant. For a limited partnership, limited liability company, or a corporation, the name of the entity. 1. LICENSE APPLICANT NAME 2. LICENSE TYPE License Type (Item 2) -- Enter the numeric designation for the applied-for license (e.g., Type 21) or a description (e.g., Off-Sale General). Premises Address (Item 3) -- Enter the location of the proposed business. Applicant Entity (Item 4) -- Check the box for the type of business ownership. Certification (Items 5 & 6) -- Check the boxes that apply and explain ownerships, interests, gifts or loans. Signature (Item 7) -- Any one signature for the certifying entity is sufficient (e.g., one general partner; one corporate officer; an LLC member, if member-run; the LLC manager, if manager-run; or LLC officer, if designated). 3. PREMISES ADDRESS (Street number and name, city, zip code) 4. APPLICANT ENTITY SOLE PROPRIETOR 5. CERTIFICATION PARTNERSHIP LIMITED LIABILITY COMPANY CORPORATION Retail License Applicant The above applicant, and/or any entity or person holding any direct or indirect ownership, management, or other interest in the applicant, and/or any entity or person in which the applicant holds any direct or indirect ownership, management, or other interest (including loans, loan guarantees and other indebtedness): does does not hold any ownership or interest, directly or indirectly, in the business, property, license, or management of any alcoholic beverage producer, rectifier, importer, or wholesaler, in California or elsewhere. Non-Retail License Applicant The above applicant, and/or any entity or person holding any direct or indirect ownership, management, or other interest in the applicant, and/or any entity or person in which the applicant holds any direct or indirect ownership, management, or other interest (including loans, loan guarantees and other indebtedness): does does not hold any ownership, directly or indirectly, in any retail license, or in the premises upon which such retail license is located, or in the furniture, fixtures or equipment in such business. is is not an agent or employee of a retail licensee. has has not furnished, given or loaned any money or other thing of value, directly or indirectly, to a retail licensee, or guaranteed the repayment of any loan or obligation owed by such retail licensee. does does not have an interest in the manufacture, importation, or distribution of distilled spirits products in California or elsewhere. 6. EXPLAIN DETAILS IF YOU CHECKED "IS", "DOES" OR "HAS" IN ITEM 5. I have read all of the above information and certifications and declare under penalty of perjury they are true, correct, and complete. 7. PRINTED NAME OF PERSON SIGNING FORM TITLE SIGNATURE DATE SIGNED X ABC-140 (12/09) American LegalNet, Inc. www.FormsWorkFlow.com