GOVERNMENT OF THE DISTRICT OF COLUMBIA ALCOHOLIC BEVERAGE REGULATION ADMINISTRATION INSTRUCTIONS FOR FILING AN ALCOHOLIC BEVERAGE CONTROL (ABC) LICENSE APPLICATION The following instructions are intended for retail and wholesale applicants who are applying for an Alcoholic Beverage Control (ABC) license. Please note that based upon the sixty day placard period and subsequent investigation, a routine application, with no protests, will take approximately 12 weeks for approval. You must call an ABC Licensing Specialist to schedule an appointment for the submission of your application. Applications will only be accepted when ALL of the information is provided. To schedule an appointment, call (202) 442-4423 between the hours of 8:30 a.m. and 4:15 p.m. Monday through Friday. FEES: All payments can be made in the form of a cashier’s check, certified check, business check, attorney’s check, personal check, or money order, payable to the D.C. Treasurer, cash, or by credit card (except for American Express). Application Fee: The fee varies. Your licensing specialist will provide you with the correct application fee that is due. There is a processing fee of $75.00. There is a transfer fee of $250.00. Entertainment Endorsement fee: This fee pertains to Restaurants, Hotels and Taverns who are applying for an Entertainment Endorsement for Entertainment, Dancing, or a Cover Charge. Please be advised that Taverns only need an Entertainment Endorsement for Entertainment, a Cover Charge or Dancing, if their dance floor is greater than 140 square feet. The fee varies. This is 20% of the base license fee. This fee is not prorated. Summer Garden/ Sidewalk Café fee: The fee is $75.00. An additional fee of $50.00 for an inspection fee will be assessed, if the Summer Garden/Sidewalk Café is applied for after the original license is granted. Tasting fee: The fee is $130.00. An additional fee of $50.00 for an inspection fee will be assessed, if the tasting permit is applied for after the original license is granted. Brew Pub fee: The fee is $3,900.00. An additional fee of $50.00 for an inspection fee will be assessed, if the brew pub permit is applied for after the original license is granted. THE APPLICATIONS MUST BE SIGNED BY THE FOLLOWING: • If the applicant is a sole proprietor, the individual must sign. • If the applicant is a partnership, all partners must sign and submit a copy of the partnership agreement. • If the applicant is a corporation, the President or Vice President must sign. • If the applicant is an LLC, the managing member(s) must sign. • If the applicant is a Limited Partnership, the general partner(s) must sign. GUIDELINES FOR REQUESTING A STIPULATED LICENSE: An application must be accepted by ABRA before a Stipulated License can be issued by the ABC Board to allow the applicant to sell and serve alcoholic beverages on the premises during the interim of the application process and approval. Only Wholesaler’s or Manufacturer’s license Class “A” and “B” or Retailer’s license Class “C” and “D” may apply for a Stipulated License. The following written correspondence must be submitted to the ABC Board: • The applicant must submit a written request for a stipulated license. The request must include the applicant’s name, trade name, and address of the premise. • The applicant must submit written correspondence from the Advisory Neighborhood Commission (ANC) where the establishment is located. The letter should include the ANC’s vote with a quorum present, not objecting to or supporting the issuance of a stipulated license prior to the completion of the notice period. The Chairperson of the Advisory Neighborhood Commission must sign this correspondence. The placard period is sixty (60) days, which includes a forty-five (45) day period for community objections. GENERAL INSTRUCTIONS: • All applications must be filed in duplicate. • All persons applying for an ABC License must be 21 years of age. • Applications must be submitted in person. Please bring valid government issued identification with you. • Please note the term “APPLICANT” as used in this application designates the person or entity in whose name the license will be issued. • Application forms must be notarized where applicable. ADVERTISEMENT INSTRUCTIONS: Upon acceptance of your application, your Licensing Specialist will provide you with placards and • instructions for the advertisement. An applicant applying for a new or transfer to a new location must provide notice to the public 60 days prior to receiving the license. This includes placarding the establishment and placing an advertisement in a local newspaper of daily circulation. • Attach extra sheets if necessary. Write, “see attachment” in any question, and print name of licensee on the top of each sheet. NOTE: The D.C. Department of Consumer & Regulatory Affairs (DCRA), Corporations Division, and the Office of Tax and Revenue (OTR) are located at 941 North Capitol Street, NE, 1st Floor, Washington, DC 20002. SPECIAL NOTICE The District of Columbia will provide the appropriate services and auxiliary aids, including sign language interpreters, whenever necessary to ensure effective communication with members of the public who are deaf, hearing impaired or who have other disabilities affecting communications. Requests for services and auxiliary aids should be made at least ten days prior to any scheduled hearing. Please notify the ADA Coordinator at (202) 442-4423. American LegalNet, Inc. www.FormsWorkflow.com Please read all questions carefully. Each question must be answered. If a question or one portion of the question does not apply; fill in the word “NONE”. ABC APPLICATION: 1. Check the category of license: Manufacturer, Wholesaler, or Retailer; 2. Check the class of license: A, B, C, or D. If you are applying for a Class A or B License, skip to question 5; 3. Check Type: Restaurant, Tavern, Nightclub, Hotel, Club, Multi-Purpose Facility, or Common Carrier; 4. Check box(s) under Entertainment Endorsement if applicable and you are applying for a Restaurant, Tavern, or Hotel License with either 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. Entertainment, Dancing, or a Cover Charge; Check box(s) under Endorsement if applicable: Sidewalk Café, Summer Garden; Tasting, or Brew Pub; Check box(s) under other types if applicable: 404.2, 405.1, Safekeeping or No Substantial Change; List the number of Seating; List the number of Hotel Rooms; If applicant is the sole proprietor or partnership print individuals name (Last Name, First Name, Middle Initial). If applicant is a business entity, list the entity’s name; Print applicant’s trade name; Print applicant’s business address; Print applicant’s mailing address if different from business address; Print applicant’s business telephone number; Print applicant’s fax number; Print applicant’s email address; Check appropriate box for type of applicant: Sole Proprietor, Corporation, Partnership, LLC or Other (LLP & LP); List the name(s), of the Sole Proprietors, or all partners; List the name(s) and titles of all Corporate Officers or LLC Members or General Partners who have an ownership interest; List number of shares; List percentage of interest. List the total number of stocks and shares distributed by Corporation. State number of authorized and the number issued; Check the appropriate box, Yes or No, as to whether any administrative action has been taken against the applicant or any person listed above regarding ABC violations in DC or any state. If yes, please explain what administrative actions were taken, location of action, and the disposition; Certification: If applicant is a sole proprietor, the individual must sign, if Partnership, each partner must sign, if Corporation, President or Vice President must sign, if LLC, managing member must sign the certification. The certification states “I hereby certify under penalty of perjury that the information in this application is true and correct. I also certify that the above applicant is the true and actual owner of the business.” Print your name and have your signature notarized. This vital document is in English, if you need this vital document translated into a different language, please answer the question: In what language do you need vital documents translated? BUSINESS INFORMATION: 1. Print Business Address; 2. Print Trade Name; 3. Print Floor(s) for area of storage; 4. Print Floor(s) of Licensed business; 5. Check the appropriate box, Yes or No, as to whether you will be the true and actual owner of the business. If no, please explain in an affidavit; 6. Check the appropriate box, Yes or No, as to whether any other business will be conducted on the premises. If yes, please explain fully; 7. Check the appropriate box, Yes or No, if you do now or have previously held a license for the sale of alcoholic beverages. If yes, please explain fully; 8. Check the appropriate box, Yes or No, as to whether any portion of the premises will be used for a dwelling or a lodging house. If yes, check the 9. 10. 11. 12. 13. 14. 15. 16. appropriate box, Yes or No, if there is interior access to the living quarters from the licensed area; If yes, explain fully. Check the appropriate box, Yes or No, if any Manufacturer, Brewery, Distiller, Wholesaler or Solicitor of alcoholic beverages, or any employee thereof, or any other individual or Corporation(s) have any financial interest directly or indirectly in this business or any other business holding an ABC license. If yes, please explain fully; List the Hours of Operation, from Sunday through Saturday under 10a. Please list the Hours of Alcoholic Beverage Sales/Service and Consumption from Sunday through Saturday under 10b. Please list Hours of Live Entertainment occurring or continuing after 6:00 p.m. from Sunday through Saturday under 10c. List the Summer Garden/Sidewalk Cafe Hours of Operation, from Sunday through Saturday under 10d. List the Summer Garden/Sidewalk Cafe Hours of Alcoholic Beverage Sales/Service and Consumption from Sunday through Saturday under 10e. List the Summer Garden/Sidewalk Cafe Hours of Live Entertainment occurring or continuing after 6:00 p.m. from Sunday through Saturday under 10f. If you checked the box for tasting in question 5 in the ABRA Application, initial at the end of this sentence that you understand that your tasting hours may not exceed your approved alcoholic beverage hours; Provide the Name, Address, and Distance (in feet) of the nearest school, public library, day care center, and recreation center; Advise how the distances were measured; Check the appropriate box Yes or No, if there is another ABC licensed establishment of the same class within 400 feet of your establishment. If yes, state name, address and distance. This is for Class “A” & “B” Only. Describe the nature of operation, including the type of food served, type of entertainment, including nude performance(s), and any goods and services to be provided. If dancing is provided please indicate dimension of the dance floor(s) and the location(s). This is for Class “C” & “D” Only. If you checked “Cover Charge” in Section 4 of in the ABRA application under Entertainment Endorsement and have a Certificate of Occupancy for over Four Hundred (400) persons, provide: (1)Public Hall Certificate of Occupancy from the Zoning Administrator and (2)Entertainment Endorsement for a Public Hall from DCRA. This is for Restaurants, Hotels & Taverns Only. American LegalNet, Inc. www.FormsWorkflow.com 17. Project the gross annual receipts from food sales for the next 12 months and describe how you arrived at that amount under 17a. Project the gross annual receipts from alcoholic beverage sales for the next 12 months and describe how you arrived at that amount under 17b. This is for Restaurants & Hotels Only. 18. Give a detailed explanation as to what effect your establishment will have on real property values on the relevant locality, section, or portion of the District of Columbia under 18a. Give a detailed explanation as to what effect your establishment will have on peace, order, and quiet including noise and litter, on the relevant locality, section or portion of the District of Columbia under 18b. Give a detailed explanation as to what effect your establishment will have upon residential parking needs and vehicular traffic and pedestrian safety under 18c. 19. Certification: If applicant is a sole proprietor, the individual must sign, if Partnership, each partner must sign, if Corporation, President or Vice President must sign, if LLC, managing member must sign the certification. The certification states “I hereby certify under penalty of perjury that the information in this application is true and correct. I also certify that the above applicant is true and actual owner of the business.” Print your name and have your signature notarized. TRANSFER CONSENT FORM: This must be completed by the Transferor as the pursuant to the license. 1. Check appropriate Category: Manufacturer, Wholesaler, or Retailer; 2. Check appropriate Class: A, B, C, or D if you are applying for Class A or B license, skip to questions 5; 3. Check appropriate Type: Restaurant, Tavern, Night Club, Hotel, Club, Multi-Purpose Facility, or Common Carrier 4. Check appropriate Entertainment Endorsement: Entertainment, Dancing, Cover Charge; 5. Check appropriate box(s) for Endorsement: Sidewalk Café, Summer Garden, Tasting or Brew Pub; 6. Check appropriate box to indicate Other Types: Safekeeping, 404.2, or 405.1; 7. Check appropriate box for Type of Applicant: Sole Proprietor, Corporation, Partnership, LLC or Other (LLP or LP); 8. Print individual or Entity’s name (Last Name, First Name, Middle Initial); 9. Print Trade Name of the establishment; 10. Print License Number; 11. Print Business Address; 12. Check appropriate box, Yes or No, as to whether there has been any administrative action taken against the applicant or any person in the entity regarding ABC violations in the District of Columbia or any state? If yes, please explain what administrative actions were taken, location of action, and disposition; 13. Certification: If applicant is a sole proprietor, the individual must sign, if Partnership, each partner must sign, if Corporation, President or Vice President must sign, if LLC, managing member must sign the certification which states “I hereby certify under penalty of perjury that the information in this form is true and correct and that the above applicant is the true and actual owner of the business. It is being requested that the Alcoholic Beverage Control Board approved the transfer of this application-print the name of transferee in the blank space. I also represent that there are no pending actions against the license business entity in the Federal or District of Columbia courts or before the ABC Board for violating Title 25 of the D.C. Official Code.” Print your name and have your signature notarized. LANDLORD AFFIDAVIT: This must be completed by the Landlord: 1. List the address of property upon which business is to be conducted; 2. List the name and address of the true and actual owner of the property; 3. Check the appropriate box, Yes or No, to indicate if a manufacturer or wholesaler has any direct or indirect financial interest in the property or business, including any money, equipment, furniture, fixtures or property either given, rented or loaned to the landlord. If yes, explain; 4. Check the appropriate box, Yes or No, and provide information as to the owner of the property having any financial interest, directly or indirectly, in the ABC license (i.e. lease, security agreement). If yes, explain. Check the appropriate box, Yes or No, as to whether you hold any other ABC license in the District of Columbia. If yes, explain. Attach copies of any financial interest in the license; 5. Certification: If Landlord is a Sole Proprietor, the individual must sign, if Partnership, each partner must sign, if Corporation, President or Vice President must sign, if LLC, managing member must sign the certification. The certification states “I hereby certify under penalty of perjury that the information in this affidavit is true and correct and attachments are true and correct.” Please print your name and have your signature notarized. PERSONAL HISTORY AFFIDAVIT: All applicants including Sole Proprietor, Partner(s), Corporate Officer(s), Director(s), Managing Member(s), General Partner(s), Investor(s), or any other person or any officer in an entity that has an ownership interest of 10% or more must each complete a personal history affidavit. 1. If this is a New Application, check this box; 2. If this is a Transfer Application, check this box; 3. If this is a Stock Transfer Application, check this box; 4. Print the trade name of the establishment; 5. Print individual’s name (Last Name, First Name, Middle Initial); 6. Print individual’s title; 7. Print individual’s residential address; 8. Print individual’s telephone number; 9. Print individual’s date of birth; 10. Print individual’s place of birth; 11. Check appropriate box, Yes or No, if you are eligible to work in the U.S. If yes, please bring in qualifying documents and provide the information requested in number 12; 12. Check the appropriate box, U.S. passport, naturalization papers, green card, visa, or work permit, and list the certificate number under 12f. and expiration date under 12g.; a. U.S. passport American LegalNet, Inc. www.FormsWorkflow.com 13. 14. 15. 16. b. naturalization papers c. green card d. visa e. work permit Check appropriate box, Yes or No, for the following questions, “Have you ever”: a. received or applied for any alcoholic beverage license in DC or any state; b. had any alcoholic beverage license suspended or revoked; c. been convicted of a misdemeanor during the last five (5) years or a felony during the last ten (10) years. If yes, attach copy of the court disposition; Check appropriate box, Yes or No, as to whether any member of your immediate family now holds an ABC license or has any financial interest, directly or indirectly, in any ABC licensed establishment in DC. Provide explanation if you answered Yes, to questions 13 or 14. Certification: You must sign this certification which states: “Certification: I hereby certify under penalty of perjury that the information in this application is true and correct.” Please have your signature notarized. PERSONAL INFORMATION RELEASE AUTHORIZATION: Sole proprietor, partner(s), corporate officer(s), director(s) of corporation, managing member(s) and general partner(s) must each complete an information release authorization affidavit. Complete this form by providing your signature, full name (typed or printed), other names used, social security number, current address, home phone number and date. Have your signature notarized. This form allows ABRA personnel to investigate you and the information contained in this application. BUSINESS INFORMATION RELEASE AUTHORIZATION: If the applicant is a Corporation, President or Vice President must sign, if LLC, managing member must sign. Complete this form by providing the full name of the business entity, the business address, the FEIN number, print your full name and title. Have your signature notarized. This form allows ABRA personnel to investigate you and the information contained in this application. FINANCIAL AFFIDAVIT: Provide trade name of the establishment. Please be sure that Section B exceeds Section A. Although you will complete this form, be advised that the Licensing Specialist or the ABC Board may request the actual documentation of the source of the monies. A. B. C. D. List the Cost/Expenses for: 1. Purchase Price for Stock/Interest, 2. Down Payment, 3. Amount Financed 4. Working Capital, 5. Inventory. Add lines 1-5 and enter the amount for Total Cost Expenses; List the total Source of Funds to satisfy the transaction. Total Source Funds must be equal to or greater than the total cost of expenses. 6. Cash on Hand, 7. Savings Account, 8. Checking Account, 9. Certification of Deposit, 10. Promissory Notes, 11. Loans, 12. Other. Add lines 6-12 and enter the amount for Total Source of Funds; Note: Account for Funds dispersed to satisfy the transaction prior to the application. If applicant is a Sole Proprietor, the individual must sign, if Partnership, each partner must sign, if Corporation, President or Vice President must sign, if LLC, managing member must sign the certification which states, “I hereby certify under penalty of perjury that the information in this application is true and correct.” Print your name and have your signature notarized. Bulk Sales Notification (If Applicable): Please read, and have your signature notarized. ATTORNEY/AGENT DESIGNATION: Have your attorney/agent complete this form, if applicable. 1. Print applicant/licensee name; 2. Print license number, if applicable; 3. Print trade name; 4. Print establishment’s address; 5. Check either box 5 if you are filing an application, check box 6, for representation in contested case(s) other than Protest Hearing, list case number; and box 7 for a Protest Hearing. If you checked box 5, check 5a. Wholesaler, 5b. Retailer, 5c. A, B, C or D, 5d. Caterer, 5e. Entertainment Endorsement, 5f. Tasting, and 5g. Sidewalk Café/ Summer Garden. 6. Contested Case(s); 7. Protest Hearing; 8. Print your name; 9. Print address 10. Print telephone number; 11. Sign your name and date. OTHER REQUIRED DOCUMENTS: Police Clearance: All applicants must obtain a police clearance from the District of Columbia’s Metropolitan Police Department, located at 300 Indiana Avenue, N.W., Washington, D.C. 20001. In addition, you must submit a police clearance for the jurisdiction in which you currently reside. Court Disposition: All persons with a misdemeanor conviction during the last five (5) years or a felony conviction during the last ten (10) years must submit a copy of the court disposition. American LegalNet, Inc. www.FormsWorkflow.com Lease: A lease is required if you are leasing the space. Please submit copies of the signed lease or letter of intent to lease. All lease documents must be signed by the property owner and contain specific authorization to sell and serve alcoholic beverages on the premises. The lease must be in the applicant’s name, i.e., sole proprietor, partnership, LLC, corporation, etc. Other Licenses: Submit copies of restaurant, grocery store, delicatessen, public hall, billiards or other business licenses. All Class C & D establishments must have a restaurant license. Photographs: Submit 5“X 7” or 7 ½” X 10” photographs depicting the exterior and interior of the premises. Photographs are to be submitted prior to the issuance of the ABC License. Menu: If you are applying for a Class C or D license, provide a copy of the menu to substantiate the type of food stated in the application. This pertains to Class C & D only. Tax Documents: • All applicants must file for a D.C. Business Tax number at the Office of Tax and Revenue (OTR). • All transferors and any transferee’s whose entity has been in existence for more than ninety (90) days must submit a Clean Hands Certification from OTR. To expedite this process, ensure that all tax documents are stamped by OTR. Documents needed from DCRA: • Certified Articles of Incorporation and Certificate of Incorporation must be submitted if you are a Corporation or if the general partner in an LLC is a corporation. Also, minutes with the corporate seal of the Board of Director’s meeting verifying the election of the officers and a copy of stock certificates must be submitted. • Articles of Organization, the Operating Agreement, Certificate of Organization and Certificate of Good Standing must be submitted if you are an LLC. Also, minutes of the Board of Director’s meeting verifying the election of the officers and a copy of stock certificates must be submitted. • Submit a copy of the Certificate of Occupancy (C of O) from DCRA. If the C of O has not been issued, apply for a Zoning Certificate and submit a letter requesting approval of the license under Section 405.1 of the ABC Regulations. This pertains to all Class “A”, “B”, “C”, and “D” applications. Additional documents required for Summer Garden/Sidewalk Cafe • • • • • Copy of Certificate of Occupancy for the number of seats for the establishment and summer garden. Note when applying to DCRA for the summer garden, indicate on the application that you are requesting a summer garden. Letter from the landlord giving permission to the applicant to sell and serve alcoholic beverages on the summer garden. Certificate of Use and a Public Space Permit is required for a sidewalk café. This document may be obtained from the District Department of Transportation (DDOT). A photograph or diagram of the establishment is required denoting the designated area for the summer garden/sidewalk café. The hours listed may not exceed DDOT or previously ABC Board approved hours. SPECIAL NOTICE The District of Columbia will provide the appropriate services and auxiliary aids, including sign language interpreters, whenever necessary to ensure effective communication with members of the public who are deaf, hearing impaired or who have other disabilities affecting communications. Requests for services and auxiliary aids should be made at least ten days prior to any scheduled hearing. Please notify the ADA Coordinator at (202) 442-4423. American LegalNet, Inc. www.FormsWorkflow.com GOVERNMENT OF THE DISTRICT OF COLUMBIA ABRA APPLICATION OFFICIAL USE ONLY License Number: Fees Paid: $ From Date Approved by Board Initial: / / Date Denied by Board / / Ward/ANC: Date Accepted: To Accepted by: Issue Date: From Hearing Date: To Initial: New Transfer Transfer With Sale Transfer without Sale Stock 1. CATEGORY 2. CLASS  Manufacturer  Wholesaler  Retailer A B C D 3. TYPE  Restaurant  Tavern  Nightclub  Hotel Storage Premise Transfer (new location) TO BE COMPLETED BY APPLICANT 4. ENTERTAINMENT ENDORSEMENT  Club  Multi-Purpose Facility  Common Carrier 6. OTHER TYPES  Sidewalk Cafe  Summer Garden  Tasting  Brew Pub  Entertainment  Dancing  Cover Charge 5. ENDORSEMENT Safekeeping  404.2  405.1  No Substantial Change 7. Number of Seating: 9. Applicant (Last Name, First Name, Middle Initial) or Entity 8. Number of Hotel Rooms: 10. Trade Name 11. Business Address 12. Mailing Address if different from business 13. Business Telephone: ( ) 16. Type of Applicant  Sole Proprietor  Corporation 17. List the name of Sole Proprietors and All Partners below. 14. Fax Number: (  Partnership 15. Email Address: )  LLC  Other (LLP or LP) 18. List all Corporate Officers, LLC Managing Members, General Partners by name and title who have an ownership interest. Number of Shares Percent of Interest 19. List the total number of stocks and shares distributed by the Corporation: Authorized _______________ Issued __________________ 20. Has there been any administrative action taken against the applicant or any person listed above regarding ABC violations in the District of Columbia or any state?  Yes  No If yes, please explain what administrative actions were taken, location of action, and the disposition. 21. If applicant is a Sole Proprietor, the individual must sign, if Partnership, each partner must sign, if Corporation, President or Vice President must sign, if LLC, managing member must sign the below certification. Certification: I hereby certify under penalty of perjury that the information in this application is true and correct. I also certify that the above applicant is the true and actual owner of the business. Printed name:______________________________________________ _________________________________________________________ Subscribed and sworn to before me ____________________________________ My commission Signature on this ____ day of_______, 20___. Notary Public expires on ___________ Printed name:______________________________________________ _________________________________________________________ Subscribed and sworn to before me ____________________________________ My commission Signature on this ____ day of_______, 20___. Notary Public expires on ___________ Printed name:______________________________________________ _________________________________________________________ Subscribed and sworn to before me ____________________________________ My commission Signature on this ____ day of_______, 20___. Notary Public expires on ___________ 22. In what language do you need vital documents translated? SPECIAL NOTICE The District of Columbia will provide the appropriate services and auxiliary aids, including sign language interpreters, whenever necessary to ensure effective communication with members of the public who are deaf, hearing impaired or who have other disabilities affecting communications. Requests for services and auxiliary aids should be made at least ten (10) days prior to any scheduled hearing. Please notify the ADA Coordinator at (202) 442-4423. American LegalNet, Inc. www.FormsWorkflow.com GOVERNMENT OF THE DISTRICT OF COLUMBIA ALCOHOLIC BEVERAGE REGULATION ADMINISTRATION BUSINESS INFORMATION 1. Business Address: 2. Trade Name 3. Floor(s) for area of storage 4. Floor(s) of licensed business 5. Will you be the true and actual owner of the business?  Yes  No If no, please explain in an affidavit. 6. Will any other business be conducted on the premises?  Yes  No If yes, please explain fully. 7. Do you have or have you previously held a license for the sale of alcoholic beverages?  Yes please explain. 8. Will any portion of the premises be used for a dwelling or a lodging house? interior access to the living quarters from the licensed area?  Yes  Yes  No  No If yes, If yes, is there  No 9. Does any manufacturer, brewery, distiller, wholesaler or solicitor of alcoholic beverages, or any employee thereof, or any other individual or corporations have any financial interest directly or indirectly in this business or any other business holding an ABC License?  Yes 10. List the hours below: Days a. Hours of Operation  No If yes, please explain fully. b. Hours of Alcoholic Beverage Sales/Service/Consumption From _________ To _________ From _________ To _________ From _________ To _________ From _________ To _________ From _________ To _________ From _________ To _________ From _________ To _________ c. Hours of Live Entertainment occurring or continuing after 6:00 PM From _________ To _________ From _________ To _________ From _________ To _________ From _________ To _________ From _________ To _________ From _________ To _________ From _________ To _________ List the hours for Summer Garden/Sidewalk Café below: Days d. Hours of Operation e. Hours of Alcoholic Beverage Sales/Service/Consumption Sunday From _________ To _________ From _________ To _________ Monday From _________ To _________ From _________ To _________ Tuesday From _________ To _________ From _________ To _________ Wednesday From _________ To _________ From _________ To _________ Thursday From _________ To _________ From _________ To _________ Friday From _________ To _________ From _________ To _________ Saturday From _________ To _________ From _________ To _________ f. Hours of Live Entertainment occurring or continuing after 6:00 PM From _________ To _________ From _________ To _________ From _________ To _________ From _________ To _________ From _________ To _________ From _________ To _________ From _________ To _________ Sunday Monday Tuesday Wednesday Thursday Friday Saturday From _________ From _________ From _________ From _________ From _________ From _________ From _________ To _________ To _________ To _________ To _________ To _________ To _________ To _________ American LegalNet, Inc. www.FormsWorkflow.com 11. If you checked the box for tasting in question 5 in the ABRA Application, initial below that you understand that your tasting hours may not exceed your approved alcoholic beverage hours. __________ 12. Provide below the name , address and distance (in feet) of the following: Name Address Distance School Public Library Day Care Center Recreation Center 13. How were the above distances measured? Answer the following if you are an off-premise consumption establishment 14. Is there another ABC licensed establishment of the same class within 400 feet of your establishment?  Yes  No If yes, state name, address and distance. 15. Answer the following if you are applying for a Hotel, Tavern, Restaurant, Night Club, Club, Multi-purpose Facility, Boat or train license. Describe the nature of operation, including the type of food served, type of entertainment, including nude performance(s), and any goods & services to be provided. If dancing is provided please indicate the dimension of the dance floor(s) and the location(s). 16. Answer the following if you are applying for a Restaurant, Hotel, or Tavern License. If you checked “Cover Charge” in Section 4 of the ABRA application instructions AND have a Certificate of Occupancy over four hundred (400) persons, please provide the following: 1) Copy of Public Hall Certificate of Occupancy from the Zoning Administrator; AND 2) Copy of Entertainment Endorsement for a Public Hall from the Department of Consumer and Regulatory Affairs. 17. Answer the following if you are a Hotel or Restaurant License. a. What are your projected gross annual receipts from food sales for the next twelve months ($ did you arrive at this amount? ). How b. What are your projected gross annual receipts from alcoholic beverage sales for the next twelve months? ($ ) How did you arrive at this amount? 18. Answer the following if you are applying for a new application or transferring ownership with a substantial change or transferring to a new location. a. Give a detailed explanation as to what effect your establishment will have on real property values on the relevant locality, section, or portion of the District of Columbia. b. Give a detailed explanation as to what effect your establishment will have on peace, order, and quiet including noise and litter, on the relevant locality, section or portion of the District of Columbia. American LegalNet, Inc. www.FormsWorkflow.com c. Give a detailed explanation as to what effect your establishment will have upon residential parking needs and vehicular traffic and pedestrian safety. If applicant is a Sole Proprietor, the individual must sign, if Partnership, each partner must sign, if Corporation, President or Vice President must sign, if LLC, managing member must sign the below certification. 19. Certification: I hereby certify under the penalty of perjury that the information in this application is true and correct. I also certify that the above licensee is the true and actual owner of the business. Printed name:______________________________ __________________________________________ Subscribed and sworn to before me Signature on this _____ day of___, 20___. ___________________________ My commission Notary Public expires on ___________. Printed name:______________________________ __________________________________________ Subscribed and sworn to before me Signature on this _____ day of___, 20___. ___________________________ My commission Notary Public expires on ___________. Printed name:______________________________ __________________________________________ Subscribed and sworn to before me Signature on this _____ day of___, 20___. ___________________________ My commission Notary Public expires on ___________. SPECIAL NOTICE The District of Columbia will provide the appropriate services and auxiliary aids, including sign language interpreters, whenever necessary to ensure effective communication with members of the public who are deaf, hearing impaired or who have other disabilities affecting communications. Requests for services and auxiliary aids should be made at least ten (10) days prior to any scheduled hearing. Please notify the ADA Coordinator at (202) 442-4423. American LegalNet, Inc. www.FormsWorkflow.com GOVERNMENT OF THE DISTRICT OF COLUMBIA ALCOHOLIC BEVERAGE REGULATION ADMINISTRATION TRANSFER CONSENT FORM 1. CATEGORY 2. CLASS  Manufacturer  Wholesaler  Retailer A B C D 3. TYPE  Restaurant  Tavern  Nightclub  Hotel 4. ENTERTAINMENT ENDORSEMENT  Club  Multi-Purpose Facility  Common Carrier  Entertainment  Dancing  Cover Charge 7. Type of Applicant  Sole Proprietor  Corporation  Partnership 8. Individual (Last Name, First Name, Middle Initial) or Entity 9. Trade Name 10. License #:  LLC 5. ENDORSEMENT 6. OTHER TYPES Sidewalk Cafe Summer Garden  Tasting  Brew Pub  Safekeeping  404.2  405.1  Other (LLP or LP) 11. Business Address: 12. Has there been any administrative action taken against the applicant or any person in the entity regarding ABC violations in the District of Columbia or any state?  Yes  No If yes, please explain what administrative actions were taken, location of action, and the disposition. If you are a Sole Proprietor, the individual must sign, if Partnership, each partner must sign, if Corporation, President or Vice President must sign, if LLC, managing member must sign the certification below. 13. Certification: I hereby certify under penalty of perjury that the information in this form is true and correct and that the above is the true and actual owner of the business. It is being requested that the Alcoholic Beverage Control Board approve the transfer of this application to: _______________________________________________________________________________. I also represent that there are no pending actions against the license business entity in the Federal or District of Columbia courts or before the ABC Board for violating Title 25 of the D.C. Official Code. Printed name:______________________________________________ _________________________________________________________ Subscribed and sworn to before me ____________________________________ My commission Signature on this ____ day of_______, 20___. Notary Public expires on ___________ Printed name:______________________________________________ _________________________________________________________ Subscribed and sworn to before me ____________________________________ My commission Signature on this ____ day of_______, 20___. Notary Public expires on ___________ Printed name:______________________________________________ _________________________________________________________ Subscribed and sworn to before me ____________________________________ My commission Signature on this ____ day of_______, 20___. Notary Public expires on ___________ Printed name:______________________________________________ _________________________________________________________ Subscribed and sworn to before me ____________________________________ My commission Signature on this ____ day of_______, 20___. Notary Public expires on ___________ Printed name:______________________________________________ _________________________________________________________ Subscribed and sworn to before me ____________________________________ My commission Signature on this ____ day of_______, 20___. Notary Public expires on ___________ Printed name:______________________________________________ _________________________________________________________ Subscribed and sworn to before me ____________________________________ My commission Signature on this ____ day of_______, 20___. Notary Public expires on ___________ SPECIAL NOTICE The District of Columbia will provide the appropriate services and auxiliary aids, including sign language interpreters, whenever necessary to ensure effective communication with members of the public who are deaf, hearing impaired or who have other disabilities affecting communications. Requests for services and auxiliary aids should be made at least ten (10) days prior to any scheduled hearing. Please notify the ADA Coordinator at (202) 442-4423. American LegalNet, Inc. www.FormsWorkflow.com GOVERNMENT OF THE DISTRICT OF COLUMBIA ALCOHOLIC BEVERAGE REGULATION ADMINISTRATION LANDLORD AFFIDAVIT 1. Address of property upon which business is to be conducted. 2. Name and address of the true and actual owner of the property. 3. Does a manufacturer or wholesaler have any direct or indirect financial interest in the property or business, including any money, equipment, furniture, fixtures or property either given, rented or loaned to landlord? Yes No If yes, please explain. 4. As the owner of the property do you have any financial interest, directly or indirectly, in the ABC license (i.e. lease, security agreement) ? Yes  No If yes, please explain. 4a. Do you hold any other ABC license in the District of Columbia? Yes  No If yes, please explain. (Copies of any financial interest in the license should be attached). If Landlord is a Sole Proprietor, the individual must sign, if Partnership, each partner must sign, if Corporation, President or Vice President must sign, if LLC, managing member must sign the below certification. 5. Certification: I hereby certify under penalty of perjury that the information in this affidavit and attachments are true and correct. Printed name:______________________________ __________________________________________ Subscribed and sworn to before me Signature on this _____ day of___, 20___. ___________________________ My commission Notary Public expires on ___________. Printed name:______________________________ __________________________________________ Subscribed and sworn to before me Signature on this _____ day of___, 20___. ___________________________ My commission Notary Public expires on ___________. Printed name:______________________________ __________________________________________ Subscribed and sworn to before me Signature on this _____ day of___, 20___. ___________________________ My commission Notary Public expires on ___________. SPECIAL NOTICE The District of Columbia will provide the appropriate services and auxiliary aids, including sign language interpreters, whenever necessary to ensure effective communication with members of the public who are deaf, hearing impaired or who have other disabilities affecting communications. Requests for services and auxiliary aids should be made at least ten (10) days prior to any scheduled hearing. Please notify the ADA Coordinator at (202) 442-4423. American LegalNet, Inc. www.FormsWorkflow.com GOVERNMENT OF THE DISTRICT OF COLUMBIA ALCOHOLIC BEVERAGE REGULATION ADMINISTRATION Personal History Affidavit Sole Proprietor, Partner(s), Corporate Officer(s), Director(s), Managing Member(s), General Partner(s), Investor(s), or any person or any officer in an entity that has an ownership interest of 10% or more. 1. New Application 4. Trade Name 2.  Transfer Application 3. Stock Transfer Application 6. Title 5. Name (Last, First, Middle Initial): 7. Residential Address: City State 8: Home Telephone Number: 9. Date of Birth: 10. Place of Birth: 11. Are you eligible to work in the United States?  Yes below:  US Passport b.  Naturalization papers c.  Work permit 12. a. d. e.  Green card  Visa  No Zip Code If yes, please bring in qualifying documents and provide the information f. Certificate number: g. Expiration date: 13. Have you ever: a. received or applied for any alcoholic beverage license in D.C. or any state or territory Yes  No b. had any alcoholic beverage license suspended or revoked  Yes  No c. been convicted of a misdemeanor during the last five (5) years or a felony during the last ten (10) years (If yes, attach a copy of the court dispositon(s).)  Yes  No 14. Does any member of your immediate family now hold an ABC license or have any financial  Yes  No interest, directly or indirectly, in any ABC licensed establishment in the District of Columbia? 15. If you have answered yes to question 13 or 14, please provide detailed information below. 16. Certification: I hereby certify under penalty of perjury that the information in this application is true and correct. ____________________________ Signature Subscribed and sworn to before me on this _____ day of___, 20___. ___________________________ Notary Public My commission expires on _____________. SPECIAL NOTICE The District of Columbia will provide the appropriate services and auxiliary aids, including sign language interpreters, whenever necessary to ensure effective communication with members of the public who are deaf, hearing impaired or who have other disabilities affecting communications. Requests for services and auxiliary aids should be made at least ten (10) days prior to any scheduled hearing. Please notify the ADA Coordinator at (202) 442-4423. American LegalNet, Inc. www.FormsWorkflow.com GOVERNMENT OF THE DISTRICT OF COLUMBIA ALCOHOLIC BEVERAGE REGULATION ADMINISTRATION PERSONAL INFORMATION RELEASE AUTHORIZATION *NOTE: A Personal Information Release Authorization form must be completed if you are one of the following: Sole Proprietor, Partner(s), Corporate Officers, Directors of Corporation, Managing Member(s), General Partner(s). CAREFULLY READ THIS AUTHORIZATION TO RELEASE INFORMATION ABOUT YOU, THEN SIGN AND DATE IN INK. I authorize any agent from the Alcoholic Beverage Regulation Administration, to obtain any information, relating to my activities, from employers, criminal justice agencies, financial or lending institutions, credit bureaus, consumer reporting agencies and retail business establishments, or individuals. This information may include, but is not limited to, my residential, personal, or criminal history record and financial and credit information. I further authorize release of my criminal history from criminal justice agencies for the purposes of determining my eligibility for a liquor license as either a licensee and/or investor. I understand that the information released is for official use by the Alcoholic Beverage Regulation Administration, and that these users may redisclose this information as authorized by law. I release any individual, including records custodians, from all liability for damages that may result to me because of compliance, or any attempts to comply, with this authorization. This release is binding, now and in the future, on my heirs, assignees, associates and personal representative(s) of any nature. Copies of the authorization that show my signature are as valid as the original release signed by me. Failure to complete this form may result in delays in obtaining your license and may result in the license being denied if this information cannot otherwise be obtained. ______________________________________________ Full Name (Print or type) ___________________________________________ Signature ______________________________________________ Other Names Used (Print or type) ___________________________________________ Social Security Number ______________________________________________ Current Address ________________________ Home Telephone Number _______________ Date I hereby certify under penalty of perjury that the foregoing information is true and correct. I further, hereby, authorize the Alcoholic Beverage Control Board or its employees to investigate any and all of the information provided by me in this application for an ABC License. ____________________________ Signature Subscribed and sworn to before me on this _____ day of___, 20___. ___________________________ Notary Public My commission expires on _____________. SPECIAL NOTICE The District of Columbia will provide the appropriate services and auxiliary aids, including sign language interpreters, whenever necessary to ensure effective communication with members of the public who are deaf, hearing impaired or who have other disabilities affecting communications. Requests for services and auxiliary aids should be made at least ten (10) days prior to any scheduled hearing. Please notify the ADA Coordinator at (202) 442-4423. American LegalNet, Inc. www.FormsWorkflow.com GOVERNMENT OF THE DISTRICT OF COLUMBIA ALCOHOLIC BEVERAGE REGULATION ADMINISTRATION BUSINESS INFORMATION RELEASE AUTHORIZATION *NOTE: An Information Release Authorization form must be completed for your business entity. Either the President or Vice President may sign if your business entity is a Corporation; Either a Managing Member(s) or General Partner(s) may sign if your business entity is a Limited Liability Company . CAREFULLY READ THIS AUTHORIZATION TO RELEASE INFORMATION ABOUT YOU, THEN SIGN AND DATE IN INK. I authorize any agent from the Alcoholic Beverage Regulation Administration, to obtain any information, relating to the business entity’s activities, financial or lending institutions, credit bureaus, consumer reporting agencies and retail business establishments, or individuals. This information may include all aspects of the business entity. I release any individual, including records custodians, from all liability for damages that may result to me because of compliance, or any attempts to comply, with this authorization. This release is binding, now and in the future, on my heirs, assignees, associates and personal representative(s) of any nature. Copies of the authorization that show my signature are as valid as the original release signed by me. Failure to complete this form may result in delays in obtaining your license and may result in the license being denied if this information cannot otherwise be obtained. ______________________________________________ Name of business entity ___________________________________________ Address ______________________________________________ FEIN # ___________________________________________ ______________________________________________ Full Legal Name ___________________________________________ Title I hereby certify under penalty of perjury that the foregoing information is true and correct. I further, hereby, authorize the Alcoholic Beverage Control Board or its employees to investigate any and all of the information provided by me in this application for an ABC License. ___________________________________Subscribed and sworn to before me Signature this _____ day of___, 20___. ___________________________ Notary Public My commission expires on __________ SPECIAL NOTICE The District of Columbia will provide the appropriate services and auxiliary aids, including sign language interpreters, whenever necessary to ensure effective communication with members of the public who are deaf, hearing impaired or who have other disabilities affecting communications. Requests for services and auxiliary aids should be made at least ten (10) days prior to any scheduled hearing. Please notify the ADA Coordinator at (202) 442-4423. American LegalNet, Inc. www.FormsWorkflow.com GOVERNMENT OF THE DISTRICT OF COLUMBIA ALCOHOLIC BEVERAGE REGULATION ADMINISTRATION FINANCIAL AFFIDAVIT Trade Name:__________________________________ A. COST/EXPENSES 1. Purchase Price for Stock/Interest 2. Down Payment 3. Amount Financed 4. Working Capital 5. Inventory $_________________ $_________________ $_________________ $_________________ $_________________ TOTAL COST OF EXPENSES $_________________ B. SOURCE OF FUNDS are to satisfy the transaction. The total Source of Funds must be equal to or greater than the Total Cost Expenses. 6. CASH ON HAND SEE (C) $_________________ 7. SAVINGS ACCOUNT SEE (C) $_________________ 8. CHECKING ACCOUNT SEE (C) $_________________ 9. CERTIFICATION OF DEPOSIT SEE (C) $_________________ 10. PROMISSORY NOTES SEE (C) $_________________ 11. LOAN(S) SEE (C) $_________________ 12. OTHER SEE (C) $_________________ TOTAL SOURCE OF FUNDS $_________________ C. NOTE: Account for funds dispersed to satisfy the transaction prior to the application. If applicant is a Sole Proprietor, the individual must sign, if Partnership, each Partner must sign, if Corporation, President or Vice President must sign, if LLC, Managing Member must sign the below certification. D. Certification: I hereby certify under penalty of perjury that the information in this application is true and correct. Printed name:______________________________ __________________________________________ Subscribed and sworn to before me Signature on this _____ day of___, 20___. ___________________________ My commission Notary Public expires on ___________. Printed name:______________________________ __________________________________________ Subscribed and sworn to before me Signature on this _____ day of___, 20___. ___________________________ My commission Notary Public expires on ___________. Printed name:______________________________ __________________________________________ Subscribed and sworn to before me Signature on this _____ day of___, 20___. ___________________________ My commission Notary Public expires on ___________. SPECIAL NOTICE The District of Columbia will provide the appropriate services and auxiliary aids, including sign language interpreters, whenever necessary to ensure effective communication with members of the public who are deaf, hearing impaired or who have other disabilities affecting communications. Requests for services and auxiliary aids should be made at least ten (10) days prior to any scheduled hearing. Please notify the ADA Coordinator at (202) 442-4423. American LegalNet, Inc. www.FormsWorkflow.com GOVERNMENT OF THE DISTRICT OF COLUMBIA ALCOHOLIC BEVERAGE REGULATION ADMINISTRATION ATTORNEY/AGENT DESIGNATION Please enter my appearance as attorney/agent for: 1. Applicant/Licensee Name: 2. License number, if applicable: 3. Trade name: 4. Establishment’s address: The purpose of the appearance form is to represent the establishment for the following reason: 5. Filing an application 6. Contested case(s) other than Protest 7. Protest Hearing for: Hearing. List case number below: a. Wholesaler b. Retailer c. A B C D d. Caterer e. Entertainment Endorsement f. Tasting g. Sidewalk café/Summer Garden 8. Print Name: 9. Address: 10. Telephone Number: ________________________________ 11. Signature __________________________ 12. Date SPECIAL NOTICE The District of Columbia will provide the appropriate services and auxiliary aids, including sign language interpreters, whenever necessary to ensure effective communication with members of the public who are deaf, hearing impaired or who have other disabilities affecting communications. Requests for services and auxiliary aids should be made at least ten (10) days prior to any scheduled hearing. Please notify the ADA Coordinator at (202) 442-4423. American LegalNet, Inc. www.FormsWorkflow.com GOVERNMENT OF THE DISTRICT OF COLUMBIA ALCOHOLIC BEVERAGE REGULATION ADMINISTRATION FOR OFFICIAL USE ONLY OFFICE OF TAX & REVENUE (OTR) BUSINESS ENTITY CLEAN HANDS CERTIFICATION  Seller A. License Number:  Buyer __________________ SIGNATURE __________________ DATE B. FEIN number: PLEASE READ CAREFULLY AND COMPLETELY BEFORE SIGNING. A FALSE STATEMENT ON THIS CERTIFICATION REQUIRES THAT THE ADMINISTRATION PROCEED IMMEDIATELY TO REVOKE THE LICENSE OR PERMIT FOR WHICH YOU ARE NOW APPLYING, AND FINE YOU $1,000.00 (ONE THOUSAND DOLLARS). THIS CERTIFICATION IS REQUIRED BY THE CLEAN HANDS ACT OF 1996; EFFECTIVE MAY 11, 1996, (D.C. LAW 11-118, D.C. OFFICIAL CODE SEC. 47-2861 et seq.) BEFORE YOU ARE ELIGIBLE TO RECEIVE A LICENSE OR PERMIT. I/We certify that the entity does not owe more than $100.00 to the District of Columbia Government as a result of: 1. 2. 3. 4. 5. 6. 7. 8. 9. Fines, penalties or interest assessed pursuant to the Litter Control Administrative Act of 1985, effective March 25, 1986 (D.C. Law 6-100; D.C. Official Code Sec. 8-801 et seq.); Fines, penalties or interest assessed pursuant to the illegal Dumping Enforcement Act of 1994, effective May 20, 1994 (D.C. Law 10-117; D.C. Official Code Sec. 8-901 et seq.); Fines, penalties or interest assessed pursuant to the Department of Consumer & Regulatory Affairs Civil Infraction Act of 1985, effective October 5, 1985 (D.C. Law 6-42; D.C. Official Code Sec. 2-1801.01 et seq.); or Past due taxes; Past due District of Columbia Water and Sewer Authority Service Fees; Traffic adjudication fines or penalties; Parking fines or penalties assessed by other jurisdictions, provided, that a reciprocity agreement is in effect between the jurisdiction and the District; Fines assessed to car dealers; and Fines assessed pursuant to the Taxicab and Limousine Commission Establishment Amendment Act of 2004. If applicant is a sole proprietor, the individual must sign, if Partnership, each partner must sign, if Corporation, President or Vice President must sign, if LLC, managing member must sign the below certification. I/We understand that if I knowingly falsify this Certification, the Administration will move to revoke the license or permit for which I am applying, and fine me $1,000.00 (one thousand dollars). I/We further understand that the Administration may conduct an investigation to ascertain the veracity of this certification. I/We understand that this Certification is now required as documentation to accompany my application for a license or permit, and that by completing this Certification, I am not guaranteed that my license or permit will be approved. Print name Print Title Signature Date signed SPECIAL NOTICE The District of Columbia will provide the appropriate services and auxiliary aids, including sign language interpreters, whenever necessary to ensure effective communication with members of the public who are deaf, hearing impaired or who have other disabilities affecting communications. Requests for services and auxiliary aids should be made at least ten (10) days prior to any scheduled hearing. Please notify the ADA Coordinator at (202) 442-4423. American LegalNet, Inc. www.FormsWorkflow.com GOVERNMENT OF THE DISTRICT OF COLUMBIA ALCOHOLIC BEVERAGE REGULATION ADMINISTRATION FOR OFFICIAL USE ONLY OFFICE OF TAX & REVENUE (OTR) CLEAN HANDS CERTIFICATION ALL INDIVIDUALS THAT HAVE AN OWNERSHIP INTEREST MUST COMPLETE THIS FORM. __________________ SIGNATURE __________________ DATE PLEASE READ CAREFULLY AND COMPLETELY BEFORE SIGNING. A FALSE STATEMENT ON THIS CERTIFICATION REQUIRES THAT THE ADMINISTRATION PROCEED IMMEDIATELY TO REVOKE THE LICENSE OR PERMIT FOR WHICH YOU ARE NOW APPLYING, AND FINE YOU $1,000.00. THIS CERTIFICATION IS REQUIRED BY THE CLEAN HANDS ACT OF 1996; EFFECTIVE MAY 11, 1996, (D.C. LAW 11118, D.C. OFFICIAL CODE SEC. 47-2861 et seq.) BEFORE YOU ARE ELIGIBLE TO RECEIVE A LICENSE OR PERMIT. I, ____________________________________________________________, as __________________________________________, (Name – Print or Type) (Applicant’s Title) certify that ___________________________________________________________, social security number ____________________ as of this date_________________________, does not owe more than $100.00 to the District of Columbia Government as a result of: 1. Fines, penalties or interest assessed pursuant to the Litter Control Administrative Act of 1985, effective March 25, 1986 (D.C. Law 6-100; D.C. Official Code Sec. 8-801 et seq.); 2. Fines, penalties or interest assessed pursuant to the illegal Dumping Enforcement Act of 1994, effective May 20, 1994 (D.C. Law 10-117; D.C. Official Code Sec. 8-901 et seq.); 3. Fines, penalties or interest assessed pursuant to the Department of Consumer & Regulatory Affairs Civil Infraction Act of 1985, effective October 5, 1985 (D.C. Law 6-42; D.C. Official Code Sec. 2-1801.01 et seq.); or 4. Past due taxes; 5. Past due District of Columbia Water and Sewer Authority Service Fees; 6. Traffic adjudication fines or penalties; 7. Parking fines or penalties assessed by other jurisdictions, provided, that a reciprocity agreement is in effect between the jurisdiction and the District; 8. Fines assessed to car dealers; and 9. Fines assessed pursuant to the Taxicab and Limousine Commission Establishment Amendment Act of 2004. I understand that if I knowingly falsify this Certification, the Administration will move to revoke the license or permit for which I am applying, and fine me $1,000.00 (one thousand dollars). I further understand that the Administration may conduct an investigation to ascertain the veracity of this certification. I understand that this Certification is required as documentation to accompany my application for a license or permit, and that by completing this Certification, I am not guaranteed that my license or permit will be approved. ____________________________________________ Signature ___________________________________________ Print Name/Title ____________________________________________ ABC Application Number ___________________________________________ ABC License Number SPECIAL NOTICE The District of Columbia will provide the appropriate services and auxiliary aids, including sign language interpreters, whenever necessary to ensure effective communication with members of the public who are deaf, hearing impaired or who have other disabilities affecting communications. Requests for services and auxiliary aids should be made at least ten (10) days prior to any scheduled hearing. Please notify the ADA Coordinator at (202) 442-4423. American LegalNet, Inc. www.FormsWorkflow.com