REQUEST FOR EXTENSION State Form 4125 (R2/10-00) Approved by State Board of Accounts, 2000 ABC USE ONLY Renewal Filed Fee paid Sales tax paid STEP 1. PERMIT INFORMATION Permit name Doing business as Premise address (number and street, city, state, ZIP code ) Permit number Telephone number Expiration date STEP 2. APPLICANT IDENTIFICATION Name of applicant Address (number and street, city, state, ZIP code ) Telephone #1 Telephone #2 Fax Number ( ) Sole-proprietor ( ) Partner ( ) Manager Check one Corporate officer STEP 3. REASON FOR EXTENSION (Check one and provide reason ) The need for an extension or the renewal of an existing permit extension is occasioned by the act or omission of the permittee or his agent thereof (e.g. 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 ALCOHOL AND TOBACCO 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 Alcohol and Tobacco 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