FORM 118 JAN 2018 PAGE 1 LIMITED LIABILITYCOMPANY (LLC) CHANGE/UPDATE OF MEMBER(S) INFORMATION 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.nebraska.gov LIMITED LIABILITY COMPANY (LLC) INFORMATION LLC Name LLC Liquor License Number DBA/TRADE NAME LLC Address City State Zip Code LLC Contact Name Contact Telephone Number LLC Email Address o All current and new members must be listed on this form (this info is cross-checked), any members not listed on this form will be deleted from the license information. Any members receiving over 25% of interest must submit form 147 and have prints taken. o If changes include a member being married or divorced a copy of the marriage certificate or divorce decree must be include. If new spouse, they must include: A photocopy of their US birth certificate, naturalization papers or current US passport Form 147 and have fingerprints taken OR file an affidavit of non-participation form 116 o If member or spouse has passed away a photocopy of death certificate must be included. Personal representative (PR) papers may be required Bar Code American LegalNet, Inc. www.FormsWorkFlow.com FORM 118 JAN 2018 PAGE 2 LIST ALL LLC MEMBER(S) MEMBER NEW CURRENT MEMBERSHIP PERCENTAGE Name: (Last, First, Middle) Date of Birth Social Security Number Home Address: (Street) City, State, Zip Code Telephone Number Email address Name of Spouse: (Last, First, Middle) Date of Birth Social Security Number MEMBER NEW CURRENT MEMBERSHIP PERCENTAGE Name: (Last, First, Middle) Date of Birth Social Security Number Home Address: (Street) City, State, Zip Code Telephone Number Email address Name of Spouse: (Last, First, Middle) Date of Birth Social Security Number MEMBER NEW CURRENT MEMBERSHIP PERCENTAGE Name: (Last, First, Middle) Date of Birth Social Security Number Home Address: (Street) City, State, Zip Code Telephone Number Email address Name of Spouse: (Last, First, Middle) Date of Birth Social Security Number MEMBER NEW CURRENT MEMBERSHIP PERCENTAGE Name: (Last, First, Middle) Date of Birth Social Security Number Home Address: (Street) City, State, Zip Code Telephone Number Email address Name of Spouse: (Last, First, Middle) Date of Birth Social Security Number MEMBER NEW CURRENT MEMBERSHIP PERCENTAGE Name: (Last, First, Middle) Date of Birth Social Security Number Home Address: (Street) City, State, Zip Code Telephone Number Email address Name of Spouse: (Last, First, Middle) Date of Birth Social Security Number American LegalNet, Inc. www.FormsWorkFlow.com FORM 118 JAN 2018 PAGE 3 The following needs to be complete by all member(s): 1. READ CAREFULLY, ANSWER COMPLETELY AND ACCURATELY 24753-125(5) Has anyone who is a party to this application, or your their spouse EVER been convicted of or plead guilty to any charge. Charge means any charge alleging a felony, misdemeanor, violation of a federal or state law; a violation of a local law, ordinance or resolution. List the nature of the charge, where the charge occurred and the year and month of the conviction or plea. Also, list any pending charges at the time of this application. If more than one party, please list charges by each individual222s name. INCLUDE TRAFFIC VIOLATIONS. Commission must be notified of any arrests and/or convictions that may occur after the date of signing this form. YES NO If yes, explain below or attach a separate page If yes, complete the following: Name: (Last, First Middle) Conviction Date (mm/yyyy) Charge Where convicted (city, state) Disposition If over 25% membership interest fingerprint cards are required from new member(s) and spouse(s). If the spouse(s) have no involvement in the day to day operation of the business they may file an affidavit of non-participation in lieu of fingerprint cards. Fingerprint cards are available at the Liquor Control Commission office upon request. Certification by Limited Liability Company Contact Under penalty of perjury, I hereby certify that each member is the real party in interest with respect to his/her position and is not acting directly or indirectly as agent, employee or representative of any other person not reported. The undersigned certifies on behalf of the LLC that it is understood that a misrepresentation of fact is cause for rejection of this application or suspension, cancellation or revocation of any license issued. Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history records of the FBI. You have the opportunity to complete or challenge the accuracy of the information contained in FBI identification record. The procedures for obtaining a change, correction, or updating an FBI identification record are set forth in Title 28, CFR, 16.34. Print Name Title Signature Date American LegalNet, Inc. www.FormsWorkFlow.com