For Official Use Only DCPLC- Removal on Stip Request Rev 7/11 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION LIQUOR CONTROL DIVISION Telephone: (860) 713-6210 Email: liquor.control@ct.gov Website: www.ct.gov/dcp Removal on Stipulation Request Form I, _________________________________________________________, have submitted a Removal application for an existing liquor permit to the Department of Consumer Protection, Liquor Control Division and hereby request to move my existing permit on a stipulated agreement. In the event my request is granted, I understand that I must complete the Stipulated Agreement for Removal form, the removal placarding process and undergo a successful inspection before the issuance of the final removal liquor permit is approved. I have attached a letter to this application describing my case for hardship. In cases of eviction, please attach an official court document to prove commencement of an eviction. Please refer to Sec 30-52 of the Connecticut General Statutes below. Sec. 30-52. Removal to another location. This section in part states "...the Department of Consumer Protection, in cases of hardship and in cases caused by reason of the commencement of an eviction action against such permittee from the particular building or place in such town specified in such permit, may endorse upon such permit permission to the permittee to remove from one building or place in any zone to another building or place in a proper business or industrial zone, and the permittee shall thereupon be authorized to remove to such new location with such permit." Signature of Backer or Authorized Representative of the Backer: X ______________________________________________________________________ Date: _____________________________ Print Name of Backer or Authorized Representative of the Backer signed above: X ______________________________________________________________________ Date: _____________________________ American LegalNet, Inc. www.FormsWorkFlow.com