ABC Form – Ownership Aff. Rev. 07/15/04 Commonwealth of Kentucky Office of Alcoholic Beverage Control 1003 Twilight Trail Frankfort, Kentucky 40601-8400 Phone (502) 564-4850 Fax (502) 564-1442 AFFIDAVIT OF OWNERSHIP Percent of Ownership List dates & states where you resided in past 5 years USA Citizen Yes / No Complete the following for the business proprietor, partner(s) and all persons interested in the business. List all owners, officers, directors, partners, managing members, members, and shareholders (unless publicly held). Show 100% of the ownership. Complete Name and Address where you reside All Phone Numbers Social Security Date of Birth Title or Nature of H = Home Number Interest in this W = Work Business F = Fax Mon. Day Year 0 = Other - - - - % - - - - % - - - - % - - - - % - - - - % - - - - % - - - - % - - - - % - - - - % WARNING: Failure to list all interested parties or making any false representations is unlawful and in violation of KRS 243.390 and will constitute grounds for denial or revocation of your license. I, (Name) _________________________________________________, (Title)______________________________ of (Business or Corporate Name) _______________________________________ Do hereby swear or affirm that all statements and information given are true and correct to the best of my knowledge, information, and belief. (Print name of person signing this affidavit) _____________________________________________________(Signature of Applicant) X_______________________________________________. Sworn to and subscribed before me this _____________________________________________day of __________________________________________________________, 20 _____________. My commission expires ________________________________________________________. Signature of Notary X_____________________________________________________________. American LegalNet, Inc. www.FormsWorkflow.com