Affidavit Of Loss Theft Or Destruction Of State Liquor License
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Affidavit Of Loss Theft Or Destruction Of State Liquor License Form. This is a Illinois form and can be use in Liquor Control Commission Statewide.
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Tags: Affidavit Of Loss Theft Or Destruction Of State Liquor License, Illinois Statewide, Liquor Control Commission
DUPLICATE LICENSE FEE
$12.00 FOR LICENSES UP TO AND INCLUDING $200.00
$24.00 FOR LICENSES OVER $200.00
AFFIDAVIT OF LOSS, THEFT OR DESTRUCTION OF STATE LIQUOR LICENSE
STATE OF ILLINOIS
County
I,
do hereby swear or affirm that State License
INSERT NAME OF AFFIANT
No.
as a(n)
of Alcoholic Liquors was issued to
CLASS OF LICENSE - RETAILER, ETC.
at
STREET ADDRESS OR RURAL ROUTE
INSERT NAME OF LICENSEE
by the Illinois Liquor Control Commission and that
the said license has been
lost
stolen
destroyed
(check whichever word applies)
, and that I have made diligent efforts to find or recover said license,
on or about
DATE
but that I have been unable to find or recover it and that it is not in my possession nor do I
have any knowledge of its present whereabouts; I futher swear or affirm that this affidavit is
made for the purpose of obtaining a duplicate of the above described license.
**INCLUDE A COPY OF YOUR LOCAL LICENSE**
SIGNATURE OF AFFIANT
Subscribed and sworn to before me this
day of
, A.D.
NOTARY PUBLIC
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