APPLICATION, TRANSFER IN OWNERSHIP ALCOHOLIC BEVERAGE RETAILER'S PERMIT RETURN TO ALCOHOLIC BEVERAGE CONTROL DIVISION P. O. BOX 540 MADISON, MS 39130-0540 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION INSTRUCTIONS Please read these instructions prior to completing this application for an alcoholic beverage retailer's permit. Each applicant must meet the statutory qualifications set by the Local Option Alcoholic Beverage Control Laws, Title 67, 1972 MCA. The Department, under authority of these laws, has established policies requiring applicants to file certain documents concerning the applicant's place of business. This application asks for particular information concerning each applicant to allow the Department to determine the eligibility of the applicant for permitting as well as the suitability of the business premises to offer for sale alcoholic beverages. This application may be typed or neatly printed in ink. Include with your application a $25.00 non-refundable processing fee. First, complete the APPLICATION FOR TRANSFER. This form is completed by the present permit holder along with the applicant and must be notarized. The transfer application will not be accepted unless this form is completed by both parties. Complete the appropriate SUPPLEMENTAL INFORMATION portion of the application for the permit type (whether package store, on-premises, on-premises private club, etc). (NOTE: An on-premises club is a chartered organization formed for the purpose other than the profiting from the sale of alcoholic beverages. Some examples of private clubs are veteran's groups, lodges, and golf clubs. Complete the STATEMENT OF OWNERSHIP. Locate on this form the ownership structure of the business, whether a sole owner, partnership, limited liability company, corporation, trust, or other. This form contains instructions on who must file qualifying documents (PERSONAL RECORD FORM, Form 1001; SUMMARY FINANCIAL STATEMENT, Form 2007; and FINGERPINT CARDS) with this application. Note that partnerships, limited liability companies, corporations, and trusts must also file a separate SUMMARY FINANCIAL STATEMENT listing the business financial status. If you have out of state banks, then a BANK CONFIRMATION Form will be required. ABC collects a pass-a-long $32.00 fee for fingerprint card processing by the Federal Bureau of Investigation. This fee is due payable with the application submission. This fee is in the form of a Cashier's Check or Money Order, payable to "ABC-FF". Each manager applicant must submit two (2) fingerprint cards with this application. The applicant must be fingerprinted by a law enforcement officer on ABC "Applicant" fingerprint cards. The cards must be complete, legible, and capable of being classified by the Federal Bureau of Investigation. Some law enforcement agencies have ABC fingerprint cards on hand. If you need fingerprint cards, contact the Permit Dept. or visit your local MS Department of Revenue District office. Signatures on each PERSONAL RECORD form must be notarized and the waiver portion WITNESSED by two (2) people. The SUMMARY FINANCIAL STATEMENT form must be completed and witnessed by two (2) people along with the Waiver portion of this form. Be sure to complete the PERMITTEE CERTIFICATION AND OATH ending this portion of the application. Next, complete the WAIVER AND AUTHORIZATION TO RELEASE INFORMATION. This release will assist us in verifying the information on your application. This form must be witnessed by two (2) people. American LegalNet, Inc. www.FormsWorkFlow.com You must submit with this application a copy of your lease, if leasing the business premises, or your deed, if you own the business premises. If a lease, the leasee must be the applicant for the alcoholic beverage permit (sole owner, partnership, Limited Liability Company, trust or corporation) and the lease must not expire for at least twelve (12) months. Include also, a FLOOR PLAN diagram of the business premises. The floor planned area is the only area where alcoholic beverages can be sold and consumed. You are required to publish notice of your application in two (2) consecutive issues of the newspaper published in the town in which the business is located. If no local newspaper exists, the notice may be published in the newspaper produced in the town located nearest your business and within the same county. The notice must be published in its entirety in TEN POINT BOLD FACE type. An acceptable legal notice format is included in this packet. Submit with this application a PUBLISHER'S AFFIDAVIT (obtained from the newspaper) as proof of publication. You must apply to the Dept. of The Treasury and furnish with this application a completed copy of TTB Form 5630.5d (7/2008). To obtain a form, go to www.ttb.gov. If you have questions or need assistance, you may call the Alcohol and Tobacco Tax and Trade Bureau at 1-800-9378864. You must register with the Dept. of Revenue and obtain a sales tax number. You may return this form with your application; or provide a copy of the form after it is filed at your local Department of Revenue District Office. Applicants can't be indebted to the State of Mississippi for any taxes, fees, or penalties. Your MISSISSIPPI INCOME TAX filing status, if applicable, will be verified for the past three (3) years. If our records indicate that you are delinquent in filing these returns (or you are indebted to the State of Mississippi for any other taxes, fees or penalties), you will be notified and must obtain clearance from your local DOR District Office before we can continue processing your application. If applicable, attach a Menu and a Copy of your Health Dept. Food Service Permit to this application. (On-premise restaurants and caters). Send the completed application to: ALCOHOLIC BEVERAGE CONTROL PERMIT DEPARTMENT P. O. BOX 540 MADISON, MS 39130-0540 Please allow four to six weeks for processing of your application. If you need assistance, call the ABC Permit Department at 601-856-1330. American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR TRANSFER IN OWNERSHIP ALCOHOLIC BEVERAGE RETAILER'S PERMIT I, , doing business as a package retailer (street) on premise retailer holding ABC Retailers Permit No. (city) (county) and located at hereby submit application to transfer this permit for change in ownership to: NAME DOING BUSINESS AS ADDRESS I certify under penalty of perjury that the information presented is true and correct to the best of