Department of Alcoholic Beverage Control LIMITED LIABILITY COMPANY QUESTIONNAIRE1.LIMITED LIABILITY COMPANY NAME2.TELEPHONE NUMBER3.PREMISES ADDRESS(Street number and name, city, zip code)4.COMPANY HEADQUARTERS ADDRESS (Street number and name, city, state, zip code)5.HEADQUARTERS TELEPHONE NUMBER6.COMPANY ATTORNEY'S NAME7.ATTORNEY'S TELEPHONE NUMBER8.COMPANY ATTORNEY'S ADDRESS(Street number and name, city, state, zip code)9.DATE LLC-1 FILED WITH SECRETARY OF STATE10. STATE WHERE LLC-1 FILED11. STATE WHERE LLC FORMED12.ARTICLES OF ORGANIZATIONWITH SECRETARY OF STATE (LLC-2 OR LLC-10) HAS BEEN AMENDED YES NO 13. OPERATING AGREEMENT DATE14. LAST AMENDMENT DATE 15.The Limited Liability Company will be managed by (check one) One Manager More than one ManagerMembersSingle Member 16.NAME OF MANAGER(S)MANAGER PRINTED NAMEMANAGER PRINTED NAMEMANAGER PRINTED NAMEMANAGER PRINTED NAME17.NAME OF OFFICERS AUTHORIZED BY ARTICLES OR AGREEMENTOFFICER PRINTED NAMEOFFICER PRINTED NAMEOFFICER PRINTED NAMEOFFICER PRINTED NAME18.LIST ALL MEMBERSMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATE19. SIGNATURE OF MANAGER OR DESIGNEEPRINTED NAMEDATE SIGNED (Use reverse for additional names if needed) ABC-256-LLC (rev. 01/) State of California Gavin Newsom, Governor I hereby certify that the above are the present managers, officers, and members of the limited liability company and that eac h s uch manager, officer, and memberisthe real partyin interestwith respectto hisor herposition and isnotacting,directlyor indirectlyasan agent, employee or representative ofany otherperson not reported to the Department.The provisions of sections23405.2 and 23405.3 of the Businessand ProfessionsCode are hereby acknowledged and itis understood that changes within the limited liability companyand/or entitiesholding interestin the limited liability company will be reported to the Departmentas required. Instructions: An individual managing member or designee may sign on behalf of the limited liability company. Attach a copy of original operating agreement and all amendments. American LegalNet, Inc. www.FormsWorkFlow.com ADDITIONAL NAMES (if needed) MEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEMEMBER'S PRINTED NAMEPERCENTAGE OF OWNERSHIPEFFECTIVE DATEABC-256-LLC (rev. 01/1) American LegalNet, Inc. www.FormsWorkFlow.com