AFFIDAVIT - TRANSFER OF STOCK OR INTEREST - CORPORATIONS/ LLC Nebraska Liquor Control Commission Licensing Department 301 Centennial Mall South PO Box 95046 Lincoln, NE 68509-5046 (Complete one for each stockholder/member) This is to certify that the alcoholic liquor license issued to the following corporation/LLC: ___________________________________________________________________________________________________________ Trade Name (dba) Name of Licensee ___________________________________________________________________________________________________________ Address of licensed premise City Total Number of Shares (If Corporation) ______________________ Liquor License Number This Corporation/LLC has issued stock/interest in the aggregate more than twenty-five percent of all the outstanding and issued stock/interest of such corporation/LLC to the following individual, being qualified to meet the standards established by law for those to whom such a license may be issued as an individual, other than residence or citizenship. ___________________________________________________________________________________________________________ Name of Shareholder (maiden name) Number of Shares issued Percentage of interest ___________________________________________________________________________________________________________ Home Address City State Zip Code ___________________________________________________________________________________________________________ Date of Birth Social Security Number ______________________________________________________________________________________________________________________ Spouse’s Name (Maiden Name) Date of Birth Social Security Number 1. READ CAREFULLY. Answer completely and accurately. Has anyone who is a party to this application, or their spouse, ever been convicted of or plead guilty to any criminal charge. Criminal charge means any charge alleging a felony or misdemeanor violation of a federal or state law; or a violation of a local law, ordinance or resolution, including any DWIs. List the nature of the charge, where the charge occurred and the year and month of the conviction or plea. Also list any charges pending at the time of this application. If more than one party, please list charges by each individual’s name No Yes List the principal residence for the past 10 years for all persons. If necessary attach a separate sheet. American LegalNet, Inc. www.FormsWorkflow.com Applicant City and State Year From To Spouse Year City and State From To The undersigned hereby consents to an investigation of his/her background including all records of every kind and description including police records, tax records, and bank or lending institution records, and said stockholder waives any right or causes of action that said applicant may have against the Nebraska Liquor Control Commission and any other individual disclosing or releasing said information to the Nebraska Liquor Control Commission. ________________________________________________ Signature of stockholder/member _________________________________________________ Signature of spouse Subscribed in my presence and sworn to before me this _____ day of _________________________________, _______. _____________________________________ notary public signature & seal pc: Nebraska State Patrol Local Clerk File FORM 35-4185 REV 7/01 American LegalNet, Inc. www.FormsWorkflow.com