ABC Name Drop Aff. Rev. 07/15/04 AFFIDAVIT FOR REMOVAL OF NAME Commonwealth of Kentucky Office of Alcoholic Beverage Control 1003 Twilight Trail Frankfort, Kentucky 40601-8400 Phone (502) 564-4850 Fax (502) 564-1442 STATE OF KENTUCKY COUNTY OF ____________________ The affiant, _______________________________________, Social Security Number ___________________ being first duly sworn, deposes and says: That he or she is over the age of twenty-one and resides at_____________________________________ ______________________________________, in the City of _________________________________________, the State of_____________________________________________, being in the County of _________________________________. That he or she owns an interest in the alcoholic beverage control license(s) privilege(s) (retail liquor drink license #) __________________________________________________________________________________________; (retail liquor by the package license #) ____________________________________________________________________; (retail beer license #) ________________________________________________________________________________. located at ___________________________________________________________________________________________ in the City of________________________________________________, Kentucky in the County of ___________________. The Affiant further states that he or she wishes to drop their name off the license(s), hereby relinquishing all rights and interest in said alcoholic beverage license privilege. X_____________________________________________________ Signature of Affiant I, the undersigned, a Notary Public in and for the State and County aforesaid, do hereby certify that _________________________ personally appeared before me and acknowledged the above to be their free act and deed. Witness my hand this _____________day of _____________________, 20_____. X ____________________________________________________ Notary Public State of ______________________________ at Large County of ______________________________ at Large My Commission Expires: _________________________. American LegalNet, Inc. www.FormsWorkflow.com