P-12(A) Request/Acknowledgement Form The following is to be completed by an entity that currently holds 10% or greater interest in more than one applicant entity or more than one entity already licensed by the Department (or both), and has been granted, or is requesting P-12(A) status: REQUESTING ENTITY: ASSOCIATED APPLICANT/LICENSEE ENTITY(S): CHECK ONE: Our designated base/master file is held in the Department's _________________ District Office under file number ____________. We are requesting P-12(A) status under file number ____________ held in the Department's ___________________ District Office. We hereby request waiver of submission of documents which would otherwise be required to establish our qualification as an entity holding 10% or greater interest in an alcoholic beverage license. We hereby attest, under penalty of perjury, that all information (including forms ABC-208 [Personal Affidavit], ABC-243 [Corporate Questionnaire], ABC-256 [Limited Partnership Questionnaire], ABC-256-LLC [Limited Liability Questionnaire] and all related supporting documents in the above-identified licensing file are accurate and current. We understand that actual licensees associated with this entity may be required to report changes to this entity, pursuant to Business and Professions Code Sections 24071, 24071.1, and/or 24071.2, and California Code of Regulations Rule 68.5. We recognize that a determination by the Department that this statement is materially false could lead to denial of an application and/or disciplinary action against any licensee associated with this entity. ___________________________________ Signature of entity representative ________________ Date ABC-812 (11/11) American LegalNet, Inc. www.FormsWorkFlow.com