APPLICATION FOR MINOR STOCK / BUSINESS REORGANIZATION State Form 50078 (9-01) h Complete and sign the following form. h Attach the requested information. h Attach a list of all permit numbers for which this applies. INSTRUCTIONS: This application may be used only when a minor stock transfer has occurred or the permit holder has changed their business organization. In order to qualify, the controlling interest of the corporation, LLC, LP or LLP may not change. A minor stock or business reorganization transfer does not require a public hearing. A controlling interest is defined as: (1) for corporations having 100 or more shareholders, the beneficial ownership, or the direct or indirect power to direct the voting of no less than 10% of the voting shares of a corporation, or (2) for any corporation having fewer than 100 shareholders, the beneficial ownership, or the direct or indirect power to direct the voting of no less than 51% of the voting shares of the corporations outstanding voting shares. STEP 1 GENERAL INFORMATION Permit Number Name of permit owner Permit address (number and street, city, state, ZIP code) __________________________________________________________________ Alternative mailing address if different from permit address (number and street, city, state, ZIP code) __________________________________________________ Telephone number 1 Name of contact Telephone number 1 STEP 2 CHANGE IN BUSINESS ORGANIZATION 2a. Was doing business as: Check one: Corporation Limited Liability Company Limited Liability Partnership Partnership Limited Partnership Proprietorship / Sole ownership Provide the information for the individuals associated with your permit as follows: Club CORPORATIONS ONLY Total shares authorized CLUB - Highest ranking officer and the financial secretary or treasurer CORPORATION - President, secretary, and all stockholders (list total shares authorized / issued and individual shares held and percent of shares issued) LIMITED LIABILITY COMPANY - All members LIMITED PARTNERSHIP / PARTNERSHIP / LIMITED LIABILITY PARTNERSHIP - All partners Total shares issued PROPRIETORSHIP - Owner * Social Security numbers are required by federal child suport law. TITLE SOC. SEC. NO. & DATE OF BIRTH SHARES HELD SSN NAME AND HOME ADDRESS % DOB SSN DOB SSN DOB SSN DOB Enclose an additional sheet if other individuals have an interest in this permit Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com 2b. Was doing business as: Corporation Limited Liability Company Partnership Limited Liability Partnership Proprietorship / Sole ownership Check one: Limited Partnership Provide the information for the individuals associated with your permit as follows: Club CORPORATIONS ONLY Total shares authorized CLUB - Highest ranking officer and the financial secretary or treasurer CORPORATION - President, secretary, and all stockholders (list total shares authorized / issued and individual shares held and percent of shares issued) LIMITED LIABILITY COMPANY - All members Total shares issued LIMITED PARTNERSHIP / PARTNERSHIP / LIMITED LIABILITY PARTNERSHIP - All partners PROPRIETORSHIP - Owner * Social Security numbers are required by federal child suport law. TITLE SOC. SEC. NO. & DATE OF BIRTH SHARES HELD SSN DOB SSN DOB SSN DOB SSN DOB NAME AND HOME ADDRESS % STEP 3 QUALIFICATIONS OF NEW OWNERS This section must be completed by any privately-held corporation, partnership or sole-proprietorship. Any corporation that is approved for public trading by the U.S. Securities and Exchange Coimmission does not need to complete this section. If you claim exemption, please initial below and provide your stock exchange abbreviation. ________ (initial) ________________________ (SEC abbreviation) Qualifications under Indiana Law for all permit holders follow. The President or Secretary of the corporation, or any partner or soleproprietor must investigate the qualifications for all members of the corporation or partnership and attest under penalties of perjury on behalf of the corporation, partnership or as a sole-proprietor that all parties with an interest in the permit meet the qualifications. 1. You must be a citizen of the United States. 2. You must be a person of good moral character and good repute in the community in which you reside. 3. You must be 21 years of age or older. 4. You must own the premises or have a bona fide lease for the full term in which the permit is to be used. 5. You must not be a law enforcement officer. 6. You must not lease or be indebted in any way by a officer or agent who hold a brewer or beer wholesaler license. 7. You must not have had an alcohol permit in Indiana be revoked or denied within the last 365 days. 8. 60% of stock is held by Indiana residents of five years, or an affidavit or intent to do $100,000 in food sales State Form 42885). I, (name) _________________________, as (position) _____________________ of (organization) ________________________ do swear or affirm under the penalties of perjury that I have conducted a bona fide investigation into the qualifications of all shareholders or partners, or I as sole-proprietor, and that all new parties with an interest in this permit meet the qualifications. I understand that any parties that do not meet these qualifications may jeopardize the permit. STEP 4 SIGNATURE AND VERIFICATION Attach minutes of meeting at chich the ownership interest change was authorized or consent of all partners and / or corporate members. Attach new Secretary of State Incorporation papers. I swear or affirm under penalties of perjury that the information in this application is true and accurate. Signature of permit owner Date signed (month, day, year) Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com