PROPERTY TAX CLEARANCE SCHEDULE - FORM NO. 1 (For a Person Business Corporation) State Form 1462 (R6 / 7-10) Approved by State Board of Accounts, 2011 Reset Form ATC permit number Expiration date (month, day, year) INDIANA ALCOHOL AND TOBACCO COMMISSION TYPE (Check all that apply) Name of individual' or company If transfer, give former name of business Mailing Address (street and number of rural route) City State ZIP Code Doing business as (DBA) New Renewal Transfer (Check all that apply) Ownership Location Stock STATUS Permit escrow DBA change Permit location (street address) City State ZIP Code I, Treasurer of ______________________________________________________ County, hereby certify that the person or company named above has paid all property taxes in 20____________ (for 20___________ assessment) and property taxes for all prior years, or is exempt from property tax by reason of __________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ Signature of County Treasurer Date (month, day, year) PROPERTY TAX CLEARANCE SCHEDULE - FORM NO. 1 (For a Person Business Corporation) State Form 1462 (R6 / 7-10) Approved by State Board of Accounts, 2011 ATC permit number Expiration date (month, day, year) INDIANA ALCOHOL AND TOBACCO COMMISSION TYPE (Check all that apply) Name of Individual or company If transfer, give former name of business Mailing Address (street and number of rural route) City State ZIP Code Doing business as (DBA) New Renewal Transfer (Check all that apply) Ownership Location Stock STATUS Permit escrow DBA change Permit location (street address) City State ZIP Code I, Treasurer of ______________________________________________________ County, hereby certify that the person or company named above has paid all property taxes in 20____________ (for 20___________ assessment) and property taxes for all prior years, or is exempt from property tax by reason of __________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ Signature of County Treasurer Date (month, day, year) American LegalNet, Inc. www.FormsWorkFlow.com