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Limited Liability Company And Corporate Report Of Changes (Liquor And 3.2 Beer Licenses) Form. This is a Colorado form and can be use in Dept Of Revenue Statewide.
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Tags: Limited Liability Company And Corporate Report Of Changes (Liquor And 3.2 Beer Licenses), DR 8177, Colorado Statewide, Dept Of Revenue
DR 8177 (05/09/08) PAGE 1
COLORADO DEPARTMENT OF REVENUE
LIQUOR ENFORCEMENT DIVISION
1375 SHERMAN STREET
DENVER CO 80261
(303) 205-2300
(2355)
(2350)
1.
21
REPORT OF CHANGES
DO NOT WRITE IN THIS SPACE
CORPORATION, LIMITED LIABILITY
COMPANY AND PARTNERSHIP
Liquor and 3.2 Beer Licenses
LLC/PARTNERSHIP
CORPORATION
SEE INSTRUCTIONS AND
FEE SCHEDULE ON PAGE 2
2. State Tax Account Number
Corporate/L.L.C./Partnership Name
3. State Liquor License Number
4. Trade Name
5. Telephone Number
6. Address of Licensed Premises
City
State
ZIP Code
7. Mailing Address if different than above
City
State
ZIP Code
8. LIST ALL officers, directors (corporation) or Managing Members (L.L.C.) or General Partner(s). Each
Officer, Director, Managing Member or Partner MUST FILL OUT a DR 8404-I (Individual History Record).
Position
Held
Names
DOB
Home Address
Replaces
9. LIST ALL 10% (or more) Stockholders or 10% (or more) Members or 10% (or more) Limited Partners.
Each person listed Must Fill out a DR 8404-I (Individual History Record)
Stockholders/Members/Partners
owning 10% (or more) of business
%
Owned
DOB
Home Address
10. Registered Agent
Replaces
Address For Service
OATH OF APPLICANT
I declare under penalty of perjury in the second degree that this application and all attachments
are true, correct, and complete to the best of my knowledge.
11. Authorized Signature
Title
Date
REPORT OF LOCAL LICENSING AUTHORITY
The foregoing changes have been received and examined by the Local Licensing Authority.
12. Local Licensing Authority For
County
Signature
Title
Town/City
Date
Attest
Date
DO NOT WRITE IN THIS SPACE – FOR DEPARTMENT OF REVENUE USE ONLY
LIABILITY INFORMATION
License Account Number
Period
Cash Fund
-100 (999)
TOTAL
▲
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DR 8177 Page 2
INSTRUCTIONS
CORPORATION, LIMITED LIABILITY COMPANY OR PARTNERSHIP REPORT of CHANGES
NOTE: ENCLOSE A CHECK PAYABLE TO THE AUTHORITY WHERE THIS APPLICATION WILL BE FILED
FOR $100.00 FOR EACH PERSON LISTED IN SECTIONS 8 AND 9 ON THE APPLICATION. MASTERFILE
APPLICANTS MUST INCLUDE A FEE OF $250.00 FOR EACH PERSON LISTED PAYABLE TO THE
COLORADO DEPARTMENT OF REVENUE. (Application filed directly to the state)
NOTE: If you are a Limited Liability Company (LLC), or a Partnership (Limited, General, or Husband and Wife)
check box 2355. For Corporations check box 2350.
Attach the following supporting documents to the Report of Changes Application:
Certificate of Incorporation (or) Date stamped Articles or, Partnership Agreement (Limited and General
Partnerships)
Certificate of Good Standing dated within the last two years
Certificate of Authority (only if a foreign corporation)
Copies of minutes of meetings by the Corporation, Limited Liability Company or Partnership supporting the
changes reflected on the front of this application. This includes letters of resignation, or appointment of any
officers, or directors of a Corporation, or any managing member or members of a Limited Liability Company,
or any general or limited partner in a Partnership (including husband and wife partnerships).
NOTE: If the Licensee as listed on Line 1 has a sole stockholder that is a Corporation, or LLC, or Partnership,
attach a letter designating one officer, or managing member or the general partner to be the "principal person"
for the applicant. This person MUST ALSO fill out a DR8404-I (Individual History Record) and submit
fingerprints for background investigation.
This application and all supporting documents must FIRST BE FILED WITH, AND APPROVED BY, THE LOCAL
LICENSING AUTHORITY (CITY, TOWN, COUNTY). Applications will not be accepted unless all applicable
questions are fully answered, all supporting documents correspond exactly with the name of the applicant.
1. List the name of the Corporation or Limited Liability Company or Partnership
2. List the State Sales Tax Number.
3. List the Applicant's State Liquor License Number.
4. List the Trade name of the business.
5. List the area code and telephone number of the business.
6. List the complete address, City, State and Zip Code, of the licensed premises.
7. List your mailing address if different than number 6 above.
8. List all officers, directors of a corporation, or all managing members of the LLC, or General Partners of
Limited or General Partnerships. List the person's Position, Home Address, Date of Birth and the name
of the person being replaced (if applicable).
9. List all 10% (or more) stockholders or members or Partners, and indicate ownership percentage, Home
Address, Date of Birth, and the name of the person they purchased ownership interest from (if applicable).
10. List the name and address for service of the Registered Agent.
11. A person authorized to sign on behalf of the Applicant must sign the application, list their title, and the date
the application was signed.
12. To be filled out by the local licensing authority only. List the name of the authority and indicate if
the authority is a county, town/city. Then sign the application, list your title and attest the city/
county officials signature and date the application.
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