INSTRUCTIONS FOR OMPLETING DBPR ABT – 6035 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO APPLICATION FOR TRANSFER OF OWNERSHIP OF AN ALCOHOLIC BEVERAGE LICENSE Application begins on page 7 If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation or your local district office. Please submit your completed application and required fee(s) to your local district office. This application may be submitted by mail, through appointment, or it can be dropped off. A District Office Address and Contact Information Sheet can be found on AB&T’s page of the DBPR web site at the link provided below. http://www.myflorida.com/dbpr/abt/district_offices/licensing.html GENERAL INSTRUCTIONS Submitting Your Application Applications for alcoholic beverage licenses and retail tobacco products dealer permits are filed with the Division of Alcoholic Beverages and Tobacco. Please complete all information. Incomplete applications will not be accepted. All questions are applicable and must be answered fully and truthfully. You must provide an original and a copy of the application and duplicate copies of all supporting documentation. All signatures must be original. If eligible, a temporary license and/or permit may be purchased. Note: When applicable, you must submit two legible and executed copies of the following: Lease, Purchase Agreements, Franchise Agreements, Management Contracts, Service Agreements, and any agreements which require a percentage payment from the business operation; Certified Copy of Death Certificate; Letters of Administration; Certificate of Title; Certified Copy of All Court Orders pertaining to the alcoholic beverage license. Florida law prohibits transfer applicants from assuming operation of a licensed establishment and selling alcoholic beverages prior to obtaining a temporary or permanent license in the transferee's name. APPLICATION REQUIREMENTS AND INSTRUCTIONS FOR COMPLETING THIS APPLICATION Application Requirements License Types Refer to the “Alcoholic Beverages and Tobacco” page on the Department of Business and Professional Regulation’s Internet site for the License Type data chart. This is provided to guide applicants in knowing how each license type is defined in order to clarify which license type suits their needs. Health Approval Health approval is required on all applications for consumption on the premises. Businesses that serve food or are located on premises licensed by the Division of Hotels and Restaurants, must obtain approval from that division. Businesses that do not serve food must contact the County Health Authority or the Department of Health. Food service establishments located in grocery and convenience stores, bakeries or delicatessens must contact the Department of Agriculture and Consumer Services. Applications must be submitted within 90 days of receiving this approval. Zoning Approval Zoning approval is executed by the city or county zoning authority in which the business to be licensed is 1 American LegalNet, Inc. www.FormsWorkflow.com located. Zoning approval is required on all applications that include a change of the licensed location unless the applicant is a state college or university located on State owned property. Zoning approval may also be required for certain change or increase in series applications. Applications must be submitted within 180 days of receiving this approval. Department of Revenue Clearance Department of Revenue clearance is required on applications for all transfer, change of location, and correction of information applications which change the licensee’s name. Applications must be submitted within 90 days of receiving this approval. Affidavit of Applicant Read and sign in the presence of a notary. The affidavit must be signed by the individual applicant, all partners of a general partnership, all general partners of a limited partnership, all managing members of a limited liability company, or one of the officers of a corporate applicant. Affidavit of Transferor The affidavit of transferor must be completed for all transfer applications. The affidavit must be signed by the individual owner, all partners of a general partnership, all general partners of a limited partnership, all managing members of a limited liability company, or a corporate officer of record. If the transfer is pursuant to operation of law or judicial proceedings, certified copies of court order(s) in which the applicant is named may be accepted in lieu of signature(s) of seller. Fingerprints Fingerprints must be submitted by each individual applicant, all corporate officers, all managing members, all general partners of a limited partnership, all partners of a general partnership, each individual stockholder owning more than .5 percent of stock, and all directors. Each applicant shall submit electronic fingerprints through the department’s vendor PearsonVue. Costs associated with the fingerprint process will be collected by PearsonVue. You may contact PearsonVue at www.pearsonvue.com or by calling 1-877-238-8232. At the time application is made to the Division of Alcoholic Beverages and Tobacco, you will need to submit your PearsonVue receipt. The receipt serves as proof of the fingerprint requirement and includes information necessary to process your application. Failure to provide this receipt will delay the processing and/or denial of your application. Note: If you are a current licensee or have been fingerprinted by this division in the past three (3) years, you are not required to submit this fingerprint information. Partner, Officer, Stockholder Personal Data - Section 4 This section of the application must be completed with original signatures for each applicant or person(s) directly connected with the business, unless they are current licensees. This will include the sole proprietor, all partners, officers, directors, individual share holders owning more than .5% of stock in nonpublic corporations, general partners of general partnerships, general partners of a limited partnership, and the managing partners of a limited liability company. Directly interested persons include anyone that is connected with the business who has a beneficial interest. It is important that each individual disclose any arrests they have had, even if they were charged, but not formally arrested, and regardless of the disposition. Social Security Number Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless a Federal statute specifically requires it or allows states to collect the number. In this instance, disclosure of social security numbers is mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and sections 409.2577, 409.2598, and 559.79, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and are used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, 2 American LegalNet, Inc. www.FormsWorkflow.com Sec. 317. The State of Florida is authorized to collect the social security number of licensees pursuant to the Social Security Act, 42 U.S.C. 405(c)(2)(C)(I). This information is used to identify licensees for tax administration purposes. Surety Bond Surety bonds are required on all new applications for manufacturers, wholesale distributors of alcoholic beverages, wholesale distributors of cigarettes, and other tobacco products. A surety bond or a rider to the original bond must be submitted on any change of business name, change of location or change of ownership name application by the aforementioned. Contact the division's Auditing Office for further information. You may wish to have Auditing review your surety bond prior to submitting this application. Corporate and Limited Partnership Registration All corporations, domestic or foreign; general partnerships; limited liability corporations; and limited partnerships are required to be registered with the Florida Secretary of State, Division of Corporations. If you have not already registered, you will need to contact the Department of State at (850) 488-9000 for further information. Your application cannot be accepted by this division without this registration. Federal Employer's Identification Number (FEIN) All licensees who pay wages to one or more employees must have a Federal Employer's Identification Number. Contact the Internal Revenue Service (IRS) at 1-800-829-3676 and request Form #SS4. Quota Transfer Fee The transfer fee on quota liquor licenses is assessed on the average annual value of gross sales of alcoholic beverages for the three (3) years immediately preceding transfer or from the date transferor acquired the license if less than three (3) years. The fee is levied at the rate of four mils and in no event exceeds $5,000. In lieu of providing records for computation of the transfer fee, the applicant may elect to pay the $5,000. The following are acceptable records for computing the transfer fee: 1. Department of Revenue sales tax records 2. Distributor records 3. Cash register receipts, bank records, accounting records and income tax records 4. In addition to documentation, a notarized affidavit of transferor estimating a percentage of gross alcoholic beverage sales when gross sales do not show a breakdown Sketch of Premises Draw, in ink, a complete sketch of the premises which includes all walls, doors, counters, sales areas, storage areas, etc. No architectural drawings are accepted. Certified Copy of Arrest Disposition If the applicant answers “yes” to any of the criminal background questions asked in this application, provide a Certified Copy of the Arrest Disposition to ensure the applicant is qualified, pursuant to Statute and Rule. Mitigation for Moral Character If the applicant is required to submit an arrest disposition, they may also be required to submit mitigation under the moral character rule. A copy of the rule and requirements can be found on AB&T’s page of the DBPR web site. Instructions on Completing this Application Sections 1 and 2 – Transaction and License Category: Trade Name: List the name under which your business will operate and as it will appear on your outside sign, menu, etc. Transaction Type: Tells us what type of application you are requesting. For example, if you are applying for a transfer of ownership, place an “X” in that block. Series Requested: ex. 1APS, 2APS, 1COP, 2COP, 4COP, 3PS Type Requested: ex. SRX, S (Not all license series have a type) 3 American LegalNet, Inc. www.FormsWorkflow.com License Category: Tells us what type of license is to be processed. Place an “X” in each box, which applies to your application. For example, if you were applying for retail alcoholic beverages you would place an “X” in each of those blocks. Refer to the AB&T page on DBPR’s Internet site for the License Type data chart. Purchasing a Temporary License: Temporary licenses are $100. (If applicable, you must provide proof of Right of Occupancy to the premises to receive a temporary license). Section 3 – License Information Applicant Name: This is to include first, middle and last name(s). If you are applying as a partnership, all partners should be listed on this line. If you are applying as a corporation, limited partnership, or other legal entity, list the exact name as registered with the Florida Secretary of State’s office. Trade Name (D/B/A): List the name under which your business will operate and as it will appear on your outside sign, menu, etc. FEIN or Social Security Number: List your FEIN number if you pay wages to one or more employees; otherwise list your Social Security number. Contact Person: List the person to whom you wish inquiries addressed. This person should be readily available during business hours to answer any questions about the licensed premises. Location Address: Provide the street address of your named business, not a P.O. Box. Location: Check the appropriate box indicating whether the license location is within the city or county. If within city limits, please identify the city in the space provided. If you are uncertain, the local zoning office should be able to assist you. Mailing Address: Provide a P.O. or street address of your named business. Section/Name (Attention): Optionally, you may indicate a person, section, or department of your company that you would like to receive correspondence. This will be included in the mailing address so that correspondence will be sent to their attention. QUESTIONS APPLY TO ALCOHOLIC BEVERAGE LICENSES ONLY Current License Number, Series, and Type: List the license number, series and type as it appears on the current license (i.e. BEV-5800595, 4COP, S). Not all license series have a type. Current Business Name: List the business name as it appears on the current license. Are you transferring this license due to revocation proceedings? Answer “Yes” or “No.” If the answer is “yes,” and there is a personal relationship (i.e. parent, spouse, child) between the applicant and the transferor, you must list the nature of the relationship. Section 4 – Partner, Officer, Stockholder Information This information is requested for all person(s) directly connected with the business unless they are current licensees. Section 5 – Description of Premises to be Licensed: Trade Name D/B/A: List the business name. Questions 1-2: Check yes or no. Question 3: Draw a sketch of the premises to be licensed (include front, back, and side roads/streets) Section 6 – Sales Tax This section must be completed by the Florida Department of Revenue on all transfer, change of location, or amended corporate name applications. 4 American LegalNet, Inc. www.FormsWorkflow.com Section 7 – Zoning This section must be completed by the local zoning authority on all change of location, transfer with a change of location, or increase in series applications. This application is to be taken to the Zoning Department (City or County) that governs the location of your business. Section 8 – Health This portion must be completed by the Division of Hotels & Restaurants or the local health authority for all consumption on the premises (COP) license applications. This includes all applications for transfer, change of location, and increase in series. Section 9 – Contracts or Agreements These are to be answered about this business for every person or entity listed. Copies of executed agreements must be submitted with this application. Section 10 – Corporate Felony Conviction Answer yes only if the applicant is a corporation and the corporation has been convicted of a felony within the last 15 years. If the answer is “yes”, list specific details. Section 11 – Special License Requirements If this application is for a quota or special license, the applicant must acknowledge the minimum requirements to be met and maintained in order to qualify for these license types. These requirements can be found on the web at http://www.myflorida.com/dbpr/abt/documents/genlaws.doc. Please indicate the appropriate special license requirement and initial and date in the designated area, if this applies to you. Section 12 – Disclosure of Interested Parties Question 1: List the names, titles and percentage of stock held for all officers, directors, stockholders, limited partners and general partners, managing members, etc. Question 2: List any persons not listed in Question 1 that are connected directly or indirectly with the business. This would include guarantors, co-signors, and lenders. Section 13 – Affidavit of Applicant(s) The application must be signed by the applicant and notarized. If a sole proprietorship, the sole proprietor must sign. If a general partnership, all partners must sign. If a corporation or other legal entity, only the signature of one officer/member, etc. is required. All signatures must be original. Section 14 – Affidavit of Transferor(s) Transfer applications must be signed by the current license holder and notarized. The rules for who must sign are the same as for Affidavit of Applicant(s). All signatures must be original. Section 15 – Current Licensee Update Data Sheet If anyone listed on this application currently holds a beverage license in the State of Florida, please complete this section. Section 16 – Department of Revenue Clearance Department of Revenue clearance is required on applications for transfer applications wherein the ownership of the license is being changed. This section of the application should be submitted directly to the Department of Revenue. Do not return with this application. 5 American LegalNet, Inc. www.FormsWorkflow.com APPLICATION CHECKLIST Select the appropriate transaction below and comply with the corresponding application requirements. TRANSACTION Transfer of Ownership APPLICATION REQUIREMENTS Pay $100 fee if requesting a temporary license (make check payable to the Department of Business and Professional Regulation) Complete DBPR ABT-6035 Division of Alcoholic Beverages and Tobacco Application for Transfer of Ownership of an Alcoholic Beverage License Certified copy of the Arrest Disposition, if applicable Mitigation for Moral Character, if applicable Contact the department’s vendor for electronic fingerprinting, PearsonVue at www.pearsonvue.com or call 1-877-238-8232 to arrange for fingerprinting. Submit the receipt issued by PearsonVue with your application. Right of Occupancy Change in Series You may request a no fee temporary license Complete DBPR ABT-6035 DBPR ABT-6035 Division of Alcoholic Beverages and Tobacco Application for Transfer of Ownership of an Alcoholic Beverage License Decrease in Series You may request a no fee temporary license Complete DBPR ABT-6035 DBPR ABT-6035 Division of Alcoholic Beverages and Tobacco Application for Transfer of Ownership of an Alcoholic Beverage License Increase in Series If requesting a temporary license, contact the district office serving your area of interest to determine the amount of the temporary license fee. (Make check payable to the Department of Business and Professional Regulation) Complete DBPR ABT-6035 Division of Alcoholic Beverages and Tobacco Application for Transfer of Ownership of an Alcoholic Beverage License 6 American LegalNet, Inc. www.FormsWorkflow.com DBPR ABT-6035 – Division of Alcoholic Beverages and Tobacco Application for Transfer of Ownership of an Alcoholic Beverage License STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION NOTE – This form must be submitted as part of an application packet If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation or your local district office. Please submit your completed application and required fee(s) to your local district office. This application may be submitted by mail, through appointment, or it can be dropped off. A District Office Address and Contact Information Sheet can be found on AB&T’s page of the DBPR web site at the link provided below. http://www.myflorida.com/dbpr/abt/district_offices/licensing.html SECTION 1 - CHECK TRANSACTION REQUESTED Trade Name (D/B/A) Transaction Type: Transfer of Ownership Change of Location Change of Business Name Change of Officers/Stockholders Change in Series Decrease in Series Increase in Series Series Requested New Retail Tobacco Products Permit Do you wish to purchase a Temporary License? Yes No Type Requested SECTION 2 - CHECK LICENSE CATEGORY Retail Alcoholic Beverages Alcoholic Beverage Broker Sales Agent Beer/Wine/Liquor Wholesaler Alcoholic Beverage Manufacturer Alcoholic Beverage Importer 7 American LegalNet, Inc. www.FormsWorkflow.com SECTION 3 – LICENSE INFORMATION If the applicant is a corporation or other legal entity, enter the name as registered with the Secretary of State on the line below. Full Name of Applicant Corporate Document # ___________________________ Trade Name (D/B/A) FEIN Number or Social Security Number* Business Telephone Number Contact Person Phone Number Location Address (Street and Number) City County State Check either: Location is within the city limits of ___________________ or Zip Code Location is in the unincorporated county Mailing Address (Street or P.O. Box) Section / Name (Attention: – Optional) City State Current Business Name Zip Code Current License Number If this application is for the transfer of this license, is the transfer due to revocation proceedings? Yes No If yes, is there any personal relationship to the transferor? Yes No If yes, explain the relationship: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 8 American LegalNet, Inc. www.FormsWorkflow.com SECTION 4 – PARTNER, OFFICER, STOCKHOLDER PERSONAL INFORMATION This section must be completed for each applicant or person(s) directly connected with the business, unless they are current licensees. 1. Trade Name (D/B/A) 2. Full Name Social Security Number* Race Sex Home Phone Number Height Weight 3. Hair Color Are you a U.S. citizen? Yes No If no, immigration card number or passport number: 4. Eye Color Date of Birth Home Address (Street and Number) City 5. State Zip Code Do you currently own or have an interest in any business selling alcoholic beverages, wholesale cigarette or tobacco products, or a bottle club? Yes No If yes, provide the information requested below. The location address should include the city and state. Trade Name (D/B/A) License Number Location Address 6. Have you ever had any type of alcoholic beverage, or bottle club license, or cigarette, or tobacco permit refused, revoked or suspended anywhere in the past 15 years? Yes No If yes, provide the information requested below. The location address should include the city and state. Trade Name (D/B/A) License Number Location Address 7. Have you been convicted of a felony or an offense involving alcoholic beverages anywhere? Yes No If yes, provide the information requested below and provide a Certified Copy of the Arrest Disposition, as requested in the Application Requirements checklist. Date Location Type of Offense 8. Have you ever been arrested or issued a notice to appear in any state of the United States or its territories? Yes No If yes, provide the information requested below and a CERTIFIED COPY OF THE DISPOSITION. Attach additional sheet if necessary: Date Location Type of Offense 9 American LegalNet, Inc. www.FormsWorkflow.com 9 Are you an official with State police powers granted by the Florida Legislature? Yes No If yes, provide details: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ _______________________________________________________________________________ NOTARIZATION STATEMENT “I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and 837.06, Florida Statutes, that I have fully disclosed any and all parties financially and or contractually interested in this business and that the parties are disclosed in Section 12 of this application. I further swear or affirm that the foregoing information is true and correct.” STATE OF___________________ COUNTY OF_________________ _________________________________________________ APPLICANT SIGNATURE The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this _______Day of______________, 20_____, By_____________________________________ who is ( ) personally known to me OR ( ) who produced ______________________________________________as identification. ________________________________________________ Commission Expires: ___________________ Notary Public (ATTACH ADDITIONAL COPIES AS NECESSARY) * Social Security Number Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless a Federal statute specifically requires it or allows states to collect the number. In this instance, disclosure of social security numbers is mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and sections 409.2577, 409.2598, and 559.79, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and are used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317. The State of Florida is authorized to collect the social security number of licensees pursuant to the Social Security Act, 42 U.S.C. 405(c)(2)(C)(I). This information is used to identify licensees for tax administration purposes. 10 American LegalNet, Inc. www.FormsWorkflow.com SECTION 5 – DESCRIPTION OF PREMISES TO BE LICENSED AB&T AUTHORIZED SIGNATURE REQUIRED Trade Name (D/B/A) 1. Yes No 2. Yes No 3. Is the proposed premises movable or able to be moved? Is there any access through the premise to any area over which you do not have dominion and control? Neatly draw a floor plan of the premises in ink, including sidewalks and other outside areas which are contiguous to the premises, walls, doors, counters, sales areas, storage areas, restrooms, bar locations and any other specific areas which are part of the premises sought to be licensed. A multi-story building where the entire building is to be licensed must show each floor plan. No architectural drawings are accepted. DBPR Authorized Signature___________________________________________ Date_________________ Approved Disapproved Comments_____________________________________________________________________________ ______________________________________________________________________________________ 11 American LegalNet, Inc. www.FormsWorkflow.com SECTION 6 – SALES TAX TO BE COMPLETED BY THE DEPARTMENT OF REVENUE Trade Name (D/B/A) The named applicant for a license/permit has complied with the Florida Statutes concerning registration for Sales and Use Tax. 1. This is to verify that the current owner as named in this application has filed all returns and that all outstanding billings and returns appear to have been paid through the period ending ___________________ or the liability has been acknowledged and agreed to be paid by the applicant. This verification does not constitute a certificate as contained in Section 212.10 (1), Florida Statutes (Not applicable if no transfer involved). 2. Furthermore, the named applicant for an Alcoholic Beverage License has complied with Florida Statutes concerning registration for Sales and Use Tax, and has paid any applicable taxes due. Signed____________________________________________________Date_____________________ Title______________________________________________________ Department of Revenue Stamp: 12 American LegalNet, Inc. www.FormsWorkflow.com SECTION 7 – ZONING TO BE COMPLETED BY THE ZONING AUTHORITY GOVERNING YOUR BUSINESS LOCATION Trade Name (D/B/A) Street Address City County State Zip Code Are there outside areas which are contiguous to the premises which are to be part of the premises sought to be licensed?” Yes No If this application is for issuance of an alcoholic beverage license where zoning approval is required, the zoning authority must complete “A”. A. The location complies with zoning requirements for the sale of alcoholic beverages or wholesale tobacco products pursuant to this application for a Series______________ license. Signed____________________________________________________Date_____________________ Title______________________________________________________ SECTION 8 – HEALTH TO BE COMPLETED BY THE DIVISION OF HOTELS AND RESTAURANTS OR COUNTY HEALTH AUTHORITY OR DEPARTMENT OF HEALTH OR DEPARTMENT OF AGRICULTURE & CONSUMER SERVICES Trade Name (D/B/A) Street Address City County State Zip Code The above establishment complies with the requirements of the Florida Sanitary Code. Signed_______________________________________________________Date____________________ Title________________________________________________ Agency____________________________ 13 American LegalNet, Inc. www.FormsWorkflow.com SECTION 9 – CONTRACTS OR AGREEMENTS These questions must be answered about this business for every person or entity listed. Copies of agreements must be submitted with this application. 1. Yes No Is there a management contract, franchise agreement, or service agreement in connection with this business? 2. Yes No Are there any agreements which require a payment of a percentage of gross or net receipts from the business operation? 3. Yes No Have you or anyone listed on this application, accepted money, equipment or anything of value in connection with this business from a manufacturer or wholesaler of alcoholic beverages? SECTION 10 – CORPORATE FELONY CONVICTION Has the applicant corporation been convicted of a felony in this state, any other state, or by the United States in the last 15 years? Yes No If the answer is “Yes,” please list all details including the date of conviction, the crime for which the corporation was convicted, and the city, county, state and court where the conviction took place. (ATTACH ADDITIONAL SHEETS IF NECESSARY) 14 American LegalNet, Inc. www.FormsWorkflow.com SECTION 11 – SPECIAL LICENSE REQUIREMENTS (DOES NOT APPLY TO BEER AND WINE LICENSES) Trade Name (D/B/A) Please check the appropriate “Special Alcoholic Beverage License” box of the license for which you are applying. Fill in the corresponding requirements for each Special License type. Quota Alcoholic Beverage License Special Alcoholic Beverage License This license is issued pursuant to ___________, Florida Statutes or Special Act, and as such we acknowledge the following requirements must be met and maintained: Please initial and date: Applicant’s Initials___________________________ Date______________ 15 American LegalNet, Inc. www.FormsWorkflow.com SECTION 12 – DISCLOSURE OF INTERESTED PARTIES Note: Failure to disclose an interest, direct or indirect, could result in denial, suspension and/or revocation of your license. Trade Name (D/B/A) 1. List below the names, titles and percentage of stock held for all officers, directors, stockholders, managing members and general partners of the corporation or other legal entity for which this license or permit is being sought. Attach extra sheets if necessary. If the applicant is a limited partnership or limited liability company, attach a list of all limited partners and members. Title/Position Name Stock % President Vice President Secretary Treasurer Director(s) Stockholder(s) Managing Member(s) General Partner(s) 2. Are there any persons not listed above who have guaranteed or co-signed a lease or loan, or any person or entity who has loaned money to the business that is not a traditional lending institution? Yes No If yes, you must list the person(s) or entity and indicate which of the below applies. Name Guarantor Co-signer Lender Interest Rate (List) 16 American LegalNet, Inc. www.FormsWorkflow.com SECTION 13 - AFFIDAVIT OF APPLICANT NOTARIZATION REQUIRED Trade Name (D/B/A) “I, the undersigned individually, or if a corporation for itself, its officers and directors, hereby swear or affirm that I am duly authorized to make the above and foregoing application and, as such, I hereby swear or affirm that the attached sketch or blueprint is substantially a true and correct representation of the premises to be licensed and agree that the place of business, if licensed, may be inspected and searched during business hours or at any time business is being conducted on the premises without a search warrant by officers of the Division of Alcoholic Beverages and Tobacco, the sheriff, his deputies, and police officers for the purposes of determining compliance with the beverage and cigarette laws.” “I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and 837.06, Florida Statutes, that I have fully disclosed any and all parties financially and or contractually interested in this business and that the parties are disclosed in section 12 of this application. I further swear or affirm that the foregoing information is true and correct.” STATE OF___________________ _________________________________________________ APPLICANT SIGNATURE COUNTY OF_________________ _________________________________________________ APPLICANT SIGNATURE The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this _______Day of______________, 20_______, By ___________________________________ who is ( ) personally known to me OR ( ) who produced ________________________________________as identification. ________________________________________________ Commission Expires: ___________________ Notary Public 17 American LegalNet, Inc. www.FormsWorkflow.com SECTION 14 - AFFIDAVIT OF TRANSFEROR NOTARIZATION REQUIRED Trade Name (D/B/A) I, the undersigned, hereby swear or affirm that I am duly authorized to make this affidavit and do hereby consent, on my behalf or on behalf of the transferor, to the above transfer, and represent to the Division of Alcoholic Beverages and Tobacco that the license which is being transferred is as shown in the application and that a bona fide sale in good faith has been made to the within applicant of the business for which the foregoing transfer of license is sought. STATE OF___________________ _________________________________________________ TRANSFEROR OR AUTHORIZED OFFICER SIGNATURE COUNTY OF_________________ _________________________________________________ TRANSFEROR OR AUTHORIZED OFFICER SIGNATURE The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this _______Day of______________, 20_____, By _____________________________________ who is ( ) personally known to me OR ( ) who produced ________________________________________as identification. ________________________________________________ Commission Expires: ___________________ Notary Public 18 American LegalNet, Inc. www.FormsWorkflow.com SECTION 15 - CURRENT LICENSEE UPDATE DATA SHEET This section is to be completed for all current alcoholic beverage and/or tobacco license holders listed on the application to ensure the most up to date information is captured. Trade Name (D/B/A) Last Name First Middle Current License Number(s) Date of Birth Social Security Number* _____/_____/_______ Street Address City State Last Name First Zip Code Middle Current License Number(s) Date of Birth Social Security Number* _____/_____/_______ Street Address City State Last Name First Zip Code Middle Current License Number(s) Date of Birth Social Security Number* _____/_____/_______ Street Address City State Last Name First Zip Code Middle Current License Number(s) Date of Birth Social Security Number* _____/_____/_______ Street Address City State Zip Code 19 American LegalNet, Inc. www.FormsWorkflow.com SECTION 16 - DEPARTMENT OF REVENUE CLEARANCE COMPLETE THIS SECTION IF APPLYING FOR A TRANSFER OF OWNERSHIP Trade Name (D/B/A) The following information is extremely important and should be read in its entirety. Because of restrictions placed on the Department of Revenue in divulging confidential tax information, the business activity of the previous owner cannot be discussed without expressed written consent. Therefore, if this application is for the transfer of an alcoholic beverage license, the following section of this form must be completed before the Department of Revenue can approve your application. If the owner is unwilling to complete this disclosure form, you may request a meeting with a Department of Revenue representative and the owner jointly to discuss any potential liability for which you could be held responsible. DO NOT RETURN THIS FORM TO AB&T WITH YOUR APPLICATION SALES TAX NOTARIZATION REQUIRED This section must be completed by the present owner of this alcoholic beverage license and must accompany your application for sales tax registration. Purchaser’s Name Business Name Sales Tax Number Location Address City State Zip Code __________________________________________________________________________ Signature of Owner, Partner or Principal Corporate Officer “I, the undersigned individually, or if a corporation, on its behalf and its officers hereby authorize the Department of Revenue to release to the above purchaser, the Division of Alcoholic Beverages and Tobacco and ______________________________________________ the status of my account number__________________________________. Seller’s Name_____________________________________________________________________ STATE OF___________________ _________________________________________________ Signature of Owner, Partner, or Principal Corporate Officer COUNTY OF_________________ The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this __________day of____________, 20___, By ___________________________________________ who is ( ) personally known to me OR ( ) who produced ______________________________________________ as identification. _________________________________________________________ Notary Public Commission Expires: ______________ Notary Public Stamp: 20 American LegalNet, Inc. www.FormsWorkflow.com FOR DIVISION USE ONLY – DO NOT WRITE BELOW THIS LINE Trade Name (D/B/A) CODE: City_____________ County___________________ TYPE FEIN NUMBER FEE TOTAL _________________________ Approved by______________________________ Date_________Audited:_________ Unaudited:________ District Office Received Date Stamp District Office Accepted Date Stamp 21 American LegalNet, Inc. www.FormsWorkflow.com DBPR ABT-6006 – Division of Alcoholic Beverages and Tobacco Quota License Transfer Fee Computation STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION NOTE – This form must be submitted as part of an application packet SECTION 1 – TRANSFER FEE COMPUTATION Trade Name (D/B/A) FIRST YEAR FIRST YEAR = SECOND YEAR THIRD YEAR _______________________________ SECOND YEAR = ______________________________ THIRD YEAR = _______________________________ TOTAL = _______________________________ divided by 3 = ______________________ X .004 = ______________________ TRANSFER FEE IF LESS THAN A FULL YEAR: $_____________________ x 12 = _________________________ 1 Month Average Average Yearly Sales 22 American LegalNet, Inc. www.FormsWorkflow.com