DCPLC-abandaff Rev 9/08 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Telephone: (860) 713-6210 Web Site: www.ct.gov/dcp ABANDONMENT AFFIDAVIT Date: _____________________ Permittee: ____________________________________________________ Trade Name: __________________________________________________ Address: ______________________________________________ ______________________________________________ ______________________________________________ Pursuant to section 30-48 (c) of Connecticut General Statutes, I attest that: Neither I, ______________________________________________________________, nor the backer _______________________________________________________, purchased anything from the previous permit holder/backer. Neither I, ________________________________________________________________, nor the backer _______________________________________________________, received any benefit from the predecessor for the abandonment of permittee/backer. I do hereby affirm that the information contained in this affidavit is true to the best of my knowledge. Signature of permittee, backer or authorized representative of the backer: X _____________________________________________________ Date: ______________________ Subscribed and affirmed before me: Signed X _________Date _______ (Commissioner of Superior Court, Notary Public, Justice of Peace) American LegalNet, Inc. www.FormsWorkflow.com