APPLICATION FOR RENEWAL OF ALCOHOLIC BEVERAGE PERMIT State Form 47 (R17 / 816) Approved by State Board of Accounts, 2016 FOR OFFICE USE ONLY Examined by/date (mm/dd/yy) Hearing date (mm/dd/yy) Issue date (mm/dd/yy) New expiration date (mm/dd/yy) Release date (mm/dd/yy) Base fee Catering INSTRUCTIONS: 1. Type or print legibly. 2. Include payment. 3. Application must be received by our office ninety (90) days before permit expires. 4. Do not complete shaded areas. 5. Please attach completed Property Tax Clearance ­ Form 1. 6. Please attach a copy of the Retail Merchant Certificate from Indiana Department of Revenue. STEP 1. GENERAL INFORMATION Name of applicant as printed on existing permit Name of business (d/b/a) Business address (number and street, city, state, ZIP code) Mailing address (number and street, city, state, ZIP code) Same as above Permit number Permit type Permit expiration date (mm/dd/yy) Business telephone area/number ( ) Home telephone area/number ( ) Status Active Nonoperational/escrow (Attach escrow letter.) Name of processor Date of renewal (mm/dd/yy) Excise district Local board 1) Have there been any changes in the existing operation, floor plans, or seating accommodations since you last applied for or renewed this permit? (If Yes, attach affidavit of changes and copies of amended floor plan on 8.5" x 11" paper, if applicable.) 2) Do you consent for the duration of the permit to inspection and search by an enforcement officer, without a warrant or other process, of your licensed premises and vehicles to determine compliance with the provision of Indiana Code 7.1? 3) Do any individuals, corporations, limited liability companies, limited liability partnerships, partnerships or stock owners, members, or partners of such entities have any interest, either directly or indirectly, in any other permits of any kind issued under Indiana Code 7.1 connected with, but not limited to, the production, distribution, transportation, or sale of alcoholic beverages? (If yes, attach a list of all permits.) 4) Since your last renewal, have you or anyone with an interest in this permit been convicted of a misdemeanor or felony? (If yes, please attach letter with dates, court, conviction, and sentence of conviction.) 5) Do you have the right to possess (rent, mortgage, or own) the permit premises for the term of the permit? 6) Have applicant's sales taxes, withholding taxes, and property tax obligation for the past year and those due at this time been paid in full? 7) Do you sell tobacco products? 8) Do you have a Type II Gaming endorsement? If yes, list Tobacco Sales Certificate Number. Yes Yes No No Yes No Yes Yes Yes No No No Yes Yes No If yes, list Gaming Endorsement Number. No STEP 2. BUSINESS OWNERSHIP Check one: Corporation Limited liability company Partnership Limited partnership Club Limited liability partnership Sole ownership Government entity Note: If the ownership has changed (by death, transfer, or sale of stock or interest, etc.) since you last applied for renewal, the processor should be notified at once before completing this section. Provide the information for the individuals associated with your permit as follows: 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 LIABLITY COMPANY ­ All members and percent of interest held LIMITED PARTNERSHIP/PARTNERSHIP/LIMITED LIABLITY PARTNERSHIP ­ All partners and percent of interest held SOLE OWNERSHIP ­ Owner GOVERNMENT ENTITY ­ Government official(s) responsible for permit TITLE (Enclose additional NAME AND HOME ADDRESS *SOCIAL SECURITY NUMBER & sheet if necessary.) (number and street, city, sate, and ZIP code) DATE OF BIRTH (mm/dd/yy) SSN DOB SSN DOB SSN DOB CORPORATIONS ONLY Total shares authorized Total shares issued SHARES OR INTEREST HELD IF APPLICABLE %** *Social Security Numbers are required by federal child support law. This agency is requesting disclosure of your Social Security Number in accordance with IC 4181; disclosure is mandatory and this record cannot be processed without it. **Percent must be included, except for a club, sole owner, or government entity. A shareholder with more than 50% ownership may individually sign transfer paperwork. American LegalNet, Inc. www.FormsWorkFlow.com  STEP 3. ANNUAL SALES/PRODUCTION (All figures are subject to verification by the Indiana Department of Revenue.) Retail or dealer permit (Skip Step 3 if permit was in escrow for the prior permit year.) 1) Do you hold a beer, wine, and liquor retail permit issued in an unincorporated area or a type 209 permit? 2) Do you hold a beer, wine, and liquor retail permit with limited bar/family room separation? 3) Do you operate a convenience store or food mart as defined by Indiana Code 7.11318.5(a)(2)? 4) Do you hold a retail or dealer permit through a partnership, corporation, limited partnership, or limited liability company that does not meet the residency requirements of Indiana Code 7.13214, 7.13215, 7.13215.2, or 7.13215.4? If you answered no to questions 14, skip to Section 4. Date of beginning report (mm/dd/yy) A. Gross food sales (For retail permits, exclude all carryout and catering sales.) (For convenience stores, exclude gasoline and automotive oil products.) Date of ending report (mm/dd/yy) B. Gross alcoholic beverage sales C. Total Gross Sales (Column A + B) Yes Yes Yes Yes No No No No Manufacturing permit (winery, farm winery, artisan distillery, distillery, and brewery) Date of beginning report (mm/dd/yy) Gallons (farm winery or distillery) or barrels (brewery) manufactured Date of ending report (mm/dd/yy) STEP 4. OPERATION INFORMATION Is there a contract of any kind to sell the permit/business at this time? Have all of your employees or servers obtained employee permits and completed employee training if required by Indiana Code 7.1? As the owner do you manage the premises? Yes Are you a grocery store or pharmacy? No Yes (If yes, move on to Step 5.) No (If no, then you MUST complete the rest of this section.) Yes Yes No No Yes No If no, does the manager of the premises have a valid manager's questionnaire on file with the ATC? The Alcohol and Tobacco Commission requires managers as follows: They must have been and Indiana resident for five (5) years or work in a restaurant with a minimum of $100,000 annual food sales; They must be a U