CONSENT TO TRANSFER State Form 49930 (R4/4-11) INSTRUCTIONS: 1. Please type or print the necessary information. 2. You must fully complete the consent to transfer. A consent must be fully completed at the time of the execution. It is not permissible to have a Consent signed in blank and completed thereafter as to dates or other information necessary to complete the Consent. If this is not fully completed at the time of execution, you may be subject to further legal action, including the revocation of your permit or criminal charges. 3. Although a validly executed Commission Consent to Transfer may evidence the Parties' intent to sell a permit pursuant to the the terms of a contract, it does not give rise to a remedy before the Commission. This type of dispute must be resolved before the appropriate trial court in the State of Indiana. 4. In the case of individuals or partners, in the event of death or divorce, please forward the appropriate court documents that address the disposition of the alcoholic beverage permit to the Alcohol and Tobacco Commission. CONSENT TO TRANSFER EXECUTED AS PART OF A PURCHASE AGREEMENT Sign this section if you hold a permit that is being transferred to another party. Submit the transfer application within 120 days of completing this Consent. I, __________________________ consent to transfer permit no. __________________ to _______________________________ on this day ________________________. This consent is being given as part of a purchase agreement in which I will divest myself of any and all interest in the permit upon completion of transfer. I have truthfully dated this Consent. I swear or affirm under penalties of perjury that the above paragraph is true. Signature of Seller Address (number and street, city, state, ZIP code ) Printed name of Seller Date of Birth (month, day, year ) Telephone number ( Date (month, day, year ) ) MAIL TO: INDIANA ALCOHOL & TOBACCO COMMISSION 302 West Washington Street, Room E114 Indianapolis, IN 46204 Phone (317) 232-2430 Attn: Consent to Transfer www.IN.gov/atc American LegalNet, Inc. www.FormsWorkFlow.com