Print Form SPOUSAL AFFIDAVIT OF NON PARTICIPATION INSERT Office Use NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN, NE 68509-5046 PHONE: (402) 471-2571 FAX: (402) 471-2814 Website: www.lcc.ne.gov I acknowledge that I am the spouse of a liquor license holder. My signature below confirms that I will have not have any interest, directly or indirectly in the operation or profit of the business (§53-125(13)) of the Liquor Control Act. I will not tend bar, make sales, serve patrons, stock shelves, write checks, sign invoices or represent myself as the owner or in any way participate in the day to day operations of this business in any capacity. I understand my fingerprint will not be required; however, I am obligated to sign and disclose any information on all applications needed to process this application. __________________________________________ Signature of spouse asking for waiver (Spouse of individual listed below) __________________________________________ Printed name of spouse asking for waiver State of _______________________________________ County of _____________________________________ The foregoing instrument was acknowledged before me this ______________________________________________ by _________________________________________________ date __________________________________________ Notary Public signature name of person acknowledged Affix Seal I acknowledge that I am the spouse of the above listed individual. I understand that my spouse and I are responsible for compliance with the conditions set out above. If it is determined that the above individual has violated (§53-125(13)) the Commission may cancel or revoke the liquor license. __________________________________________ Signature of individual involved with application (Spouse of individual listed above) __________________________________________ Printed name of applying individual State of _______________________________________ County of _____________________________________ The foregoing instrument was acknowledged before me this __________________________________________ by _____________________________________________________ date __________________________________________ Notary Public signature name of person acknowledged Affix Seal In compliance with the ADA, this spousal affidavit of non participation is available in other formats for persons with disabilities. A ten day advance period is requested in writing to produce the alternate format. FORM 35-4178 Revised 1/2008 American LegalNet, Inc. www.FormsWorkflow.com