KANSAS DEPARTMENT OF REVENUE ALCOHOLIC BEVERAGE CONTROL DIVISION New Renewal OWNERSHIP DISCLOSURE FORM REVIEW ATTACHED INSTRUCTIONS FOR FURTHER CLARIFICATION - INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED SECTION 1: BUSINESS INFORMATION TYPE OF BUSINESS Individual Corporation Partnership LLC LP TYPE OF LICENSE Class A Hotel/DE Nonbeverage Class B Hotel/DE/Caterer Manufacturer Drinking Est. (DE) Retail Liquor Store Wine Distr. Caterer Farm Winery Beer Distr. DE/Caterer Microbrewery Spirits Distr. LICENSEE NAME Individual/Partnership/Corporation/LLC/LP Name DBA (Doing Business As) NAME LOCATION ADDRESS OF BUSINESS Street City LICENSE NUMBER County Zip FEIN (Renewal Applications Only) SECTION 2: The following information must be provided on the applicant(s); individual owners; partners; all officers, managers, and directors (if a corporation or LLC); and anyone with a financial interest, PLUS the spouses of all submitted persons. (ATTACH ADDITIONAL PAGES AS NECESSARY.) LAST NAME FIRST NAME MIDDLE NAME RACE GENDER DATE OF BIRTH BIRTHPLACE OTHER NAMES USED SOCIAL SECURITY NO. MAIDEN NAME DRIVER'S LICENSE NO. HOME ADDRESS LAST NAME FIRST NAME STATE CITY DRIVER'S LICENSE NO. FIRST NAME STATE DRIVER'S LICENSE NO. FIRST NAME ZIP CODE DAYTIME PHONE DATE OF BIRTH BIRTHPLACE RACE POSITION STATE GENDER MARITAL STATUS ZIP CODE DAYTIME PHONE DATE OF BIRTH BIRTHPLACE % OWNERSHIP STATE CITY COUNTY MIDDLE NAME RACE POSITION STATE GENDER MARITAL STATUS ZIP CODE DAYTIME PHONE DATE OF BIRTH BIRTHPLACE MAIDEN NAME DRIVER'S LICENSE NO. HOME ADDRESS ABC-280-OD MARITAL STATUS MAIDEN NAME OTHER NAMES USED SOCIAL SECURITY NO. GENDER COUNTY MIDDLE NAME HOME ADDRESS LAST NAME STATE % OWNERSHIP CITY OTHER NAMES USED SOCIAL SECURITY NO. RACE POSITION MAIDEN NAME HOME ADDRESS LAST NAME COUNTY MIDDLE NAME OTHER NAMES USED SOCIAL SECURITY NO. % OWNERSHIP STATE CITY Page 1 of 2 % OWNERSHIP POSITION COUNTY STATE ZIP CODE MARITAL STATUS DAYTIME PHONE Rev. 07/2003 American LegalNet, Inc. www.FormsWorkflow.com KANSAS DEPARTMENT OF REVENUE ALCOHOLIC BEVERAGE CONTROL DIVISION Ownership Disclosure Form SECTION 3: BACKGROUND QUALIFICATIONS (If the answer to any question is yes, provide explanation on separate page) Yes No 1) Has any person listed in Section 2 been convicted of a felony in Kansas or in any other state, or under federal law? 2) Has any person listed in Section 2 been convicted of a morals charge (prostitution; procuring any person; solicitation of a child under 18 for immoral act involving sex; possession or sale of narcotics, marijuana, amphetamines or barbiturates; rape; incest; gambling; adultery; or bigamy) in Kansas or any other state? 3) Has any person listed in Section 2 had an alcoholic liquor or cereal malt beverage license revoked in Kansas or in any other state? 4) Is any person listed in Section 2 currently a law enforcement officer or a non-elected official who supervises or appoints any law enforcement officer? 5) Does any person listed in Section 2 have an ownership interest in any other business licensed to sell alcoholic liquor or cereal malt beverage in Kansas or any other state? If so, please provide license number 6) Does any person listed in Section 2 not meet the Kansas residency requirement for the type of license applied for? (1 Year - Class A & B Club, Drinking Establishment; 4 Years - Retail Liquor, Microbrewery, Farm Winery; 5 Years - Manufacturer) If so, please explain 7) Has any person listed in Section 2 been a citizen of the United States for less than 10 years? (New Applicants Only) Please list all that apply SECTION 4: APPOINTMENT OF PROCESS AGENT WITH POWER OF ATTORNEY LAST NAME FIRST NAME MIDDLE NAME RACE OTHER NAMES USED GENDER DATE OF BIRTH BIRTHPLACE MAIDEN NAME SOCIAL SECURITY NO. DRIVER'S LICENSE NO. HOME ADDRESS STATE CITY %OWNERSHIP COUNTY STATE POSITION ZIP CODE MARITAL STATUS DAYTIME PHONE SECTION 5: PRIMARY CONTACT PERSON* FROM SECTION 2 TO WHOM ABC WILL DIRECT INQUIRIES LAST NAME FIRST NAME MIDDLE NAME POSITION DAYTIME PHONE * Complete if different from Process Agent SECTION 6: APPLICATION OATH STATE OF COUNTY OF I, , being first duly sworn, upon oath deposes and says: Applicant This information is provided in support of an application for licensure under chapter 41 of the Kansas Statutes Annotated. I have read and signed the same and the information contained in document and all application materials represents a true, accurate and complete disclosure of information under penalties of perjury. I hereby authorize disclosure and investigation of my financial records including those held by third parties to duly authorized agents of the Director of Alcoholic Beverage Control as necessary to determine qualification for licensure. Furthermore, if a Corporation or LLC, I appoint the Process Agent with Power of Attorney identified in Section 4, who is a UNITED STATES CITIZEN and KANSAS RESIDENT, upon whom process may be served in any action brought against it. Signature of applicant Date NOTARY SEAL Subscribed in my presence and sworn to before me this day of , . My commission expires: Notary Public ABC-280-OD Page 2 of 2 Rev. 07/2003 American LegalNet, Inc. www.FormsWorkflow.com KANSAS DEPARTMENT OF REVENUE ALCOHOLIC BEVERAGE CONTROL DIVISION OWNERSHIP DISCLOSURE - ATTACHMENT A New Applicants Only If more space is needed, provide explanation on separate page SOURCE OF FUNDS The total amount you have invested or will invest to open this business including cash (including currency and financial asset accounts), notes, loans and operating capital: Amount: $______________ DOLLAR AMOUNT BY SOURCE Identify the sources of all funds (including asset financial accounts and loans) you have invested or will invest in this business as listed above. List all bank account numbers and the amount derived from each source. Also identify all persons authorized to sign on, or who are part owners of said account(s). Attach copies of promissory notes or loan agreements along with amortization schedule used for this business. For cash accounts, attach a copy of the latest bank account statement. Amount Sources & Account Numbers SSN or FEIN Names of authorized persons on account $ $ $ $ $ $ $ $ CASH OTHER THAN IN FINANCIAL ACCOUNTS U.S. currency you accumulated over time that you will invest in the business. OWNERSHIP OF FURNITURE AND EQUIPMENT Do you own the furniture, fixtures and equipment at the proposed licensed location? If "No," state from whom leased: Name: Total Amount $ Yes No ACCOUNTANT/BOOKKEEPER List the name, address and telephone number of the accountant or bookkeeper for your business (if applicable). Name Street Address City, State & Zip Code Telephone ABC-280-OD-Attachment A ( ) - Rev. 07/2003 American LegalNet, Inc. www.FormsWorkflow.com