COUNTY VERIFICATION OF BUSINESS LOCATION ALCOHOL & TOBACCO COMMISSION State Form 44184 (R4/10-10) 302 W. Washington Street, Room E114 Indianapolis, IN 46204 http://www.IN.gov/atc TO THE INDIANA ALCOHOL AND TOBACCO COMMISSION: I verify that _____________________________________________________________________ (Address) ALL COUNTIES EXCEPT MARION COUNTY is within the corporate limits of city or town of_____________________________. is outside the corporate limits of city or town of_____________________________. the premises is located outside the corporate limits of an incorporated city or town and the premises are within, or in immediate proximity to an unincorporated town, which unincorporated town meets these qualifications: (1) which has been a settlement or a group of residences for more than ten (10) years; (2) to which the inhabitants of the surrounding countryside resort for purchases or public (3) which has borne a name and has been known by that name for more than ten (10) years. The county surveyor of the county in which the premises is located shall certify the information set forth below: _____________________________________________ are within or are in immediate (Address) proximity to the unincorporated town known as_______________________________ ______________________________________________ , which has borne this name and has been known by this name for more than ten (10) years and has been a settlement or a group of residences for more than ten (10) years to which the inhabitants of the surrounding countryside resort for purchases, public meetings, or as a community or neighborhood center. MARION COUNTY ONLY Is within the corporate limits of a consolidated city and is within the corporate limits of the excluded city or town of________________________. is within the corporate limits of the included city or town of ________________________. is within the special fire district. is outside the corporate limits of all the special service fire district and all excluded or included cities or towns. Signature of County Surveyor Date (month, date, year) American LegalNet, Inc. www.FormsWorkFlow.com