STATE OF CONNECTICUT LIQUOR CONTROL DIVISION AGE STATEMENT FORM Date: , 20 I, , hereby represent to , a permittee of the Connecticut Department of Consumer Protection, that I am over the age of 21 years, having been born on , 20, at . This statement is made to induce said permittee to sell or otherwise furnish alcoholic beverages to the undersigned. I understand that Title 30 of the General Statutes prohibits the sale of alcoholic liquor to any person who is not twenty-one years of age. I understand that I am subject to a fine of one hundred dollars for the first offense and not more than two hundred fifty dollars for each subsequent offense for willfully misrepresenting my age for the purposes set forth in this statement. Name: Home Address: Type of ID: ID Number: STATE OF CONNECTICUT LIQUOR CONTROL DIVISION AGE STATEMENT FORM Date: , 20 I, , hereby represent to , a permittee of the Connecticut Department of Consumer Protection, that I am over the age of 21 years, having been born on , 20, at . This statement is made to induce said permittee to sell or otherwise furnish alcoholic beverages to the undersigned. I understand that Title 30 of the General Statutes prohibits the sale of alcoholic liquor to any person who is not twenty-one years of age. I understand that I am subject to a fine of one hundred dollars for the first offense and not more than two hundred fifty dollars for each subsequent offense for willfully misrepresenting my age for the purposes set forth in this statement. Name: Home Address: Type of ID: ID Number: American LegalNet, Inc. www.FormsWorkFlow.com