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Affidavit-Transfer Of Stock Or Interest-Corporation-LLC Form. This is a Nebraska form and can be use in Liquor Control Commission Statewide.
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Tags: Affidavit-Transfer Of Stock Or Interest-Corporation-LLC, 35-4185, Nebraska Statewide, Liquor Control Commission
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.
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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
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