GOVERNMENT OF THE DISTRICT OF COLUMBIA Alcoholic Beverage Regula on Administra on 23 DCMR §§ 903 and 904 Gifts and Loans from Wholesalers and Manufacturers Disclosure Form Name of entity contributing the item or service. Mail Alcoholic Beverage Regulation Administration Attn: Licensing Division 2000 14th Street, NW, Suite 400 South Washington, D.C. 20009 Fax 202.442.9563 Email MyABCLicense.ABRA@DC.gov Board approval is not required for an individual transmittal having a value of less than fifty dollars ($50). Date of Event: _______________________ From: _______________________ (License No.) _______________________ (Trade Name) _______________________ (Address) A. The applicant requests permission to distribute the following item or service to licensees: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ B. The item/service is a (check one): C. Value of item: $ _______________ Purchase Rental Loan Gi D. Each License listed has received the exact same item/service as described above: Yes Yes No No E. The service or ar cle of property does not exceed $500.00 for each individual occurrence: F. List the name of Licensee(s) receiving the item or service described above. License Number Trade Name Address Signature: ___________________________________ Date: ___________________ American LegalNet, Inc. www.FormsWorkFlow.com