REQUEST FOR EXTENSION ABC USE ONLY State Form 4125 (R2/10-00 ___ Renewal Filed Approved by State Board of Accounts, 2000 ___ Fee paid ___ Sales tax paid STEP 1. PERMIT INFORMATION Permit name Permit number Expiration date Doing business as Telephone number Premise address (number and street, city, state, ZIP code ) STEP 2. APPLICANT INFORMATION Name of applicant Address (number and street, city, state, ZIP code ) Telephone #1 Telephone #2 Fax Number ( ( ( ) ) ) Check one ____ Sole-proprietor ____ Corporate officer ____ Partner ____ Manager STEP 3. REASON FOR EXTENSION (Check one and provide reason ) ____ The need for an extension (or its renewal ) is occasioned by the act or omission of the permittee or his agent thereof (eg. Attorney, accountant, preparer, etc.). A $50.00 extension fee is required. PAY BY CASHIER'S CHECK, CERTIFIED CHECK, BUSINESS CHECK, OR MONEY ORDER TO THE "INDIANA ALCOHOLIC BEVERAGE COMMISSION" (PERSONAL CHECKS CANNOT BE ACCEPTED ) Reason: ____ The need for an extension or the renewal of an existing extension is occasioned by the act or omission of the Alcoholic Beverage Commission, a local board, or an unrelated third party who is not an employee of the permittee nor under the control of the permittee. Reason: STEP 4. SIGNATURE I affirm under penalties of perjury that all statements in this request are true and that all sales taxes have been paid. Signature of applicant Date (month, day, year ) American LegalNet, Inc. www.FormsWorkFlow.com