INSTRUCTIONS FOR COMPLETING DBPR ABT – 6025 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO REVERTER AFFIDAVIT FOR QUOTA LICENSES Application begins on page 2 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 to your local district office. This application may be submitted by mail, through appointment, or it can be dropped off. 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 This application should be used when an applicant withdraws an application for the transfer of a quota license. This also applies to applications that are disapproved or non-consummated by the Division. GENERAL INSTRUCTIONS Please complete all information. All questions are applicable and must be answered fully and truthfully. You must provide an original and a copy of the application. All signatures must be original. APPLICATION CHECKLIST TRANSACTION Reverter for Quota Licenses APPLICATION REQUIREMENTS Complete DBPR ABT-6025 Division of Alcoholic Beverages and Tobacco Reverter Affidavit for Quota Licenses 1 American LegalNet, Inc. www.FormsWorkflow.com DBPR ABT-6025 – Division of Alcoholic Beverages and Tobacco Reverter Affidavit for Quota Licenses STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION 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 to your local district office. This application may be submitted by mail, through appointment, or it can be dropped off. 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 License Number LICENSE INFORMATION Series Licensee of Record Transferee Business Name (D/B/A) Location Address City County State Zip Code The application for transfer of the above referenced quota alcoholic beverage license has been withdrawn by the applicant, disapproved, or non-consummated by the Division of Alcoholic Beverages and Tobacco: I certify that ownership of the licensed business reverted to me. I further certify that I am now operating said business, either personally or by my authorized employees, and expect to continue to operate said business until a transfer of the alcoholic beverage license is approved. I certify that ownership of the licensed business reverted to me. I further certify that I will make application to place the above referenced license in escrow; or if the license was in escrow at the time of transfer, I will request an extension of the escrow period, if applicable. STATE OF___________________ _________________________________________________ APPLICANT (Signature must be notarized) COUNTY OF_________________ _________________________________________________ APPLICANT (Signature must be notarized) 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 2 Commission Expires: _______________ American LegalNet, Inc. www.FormsWorkflow.com