REQUEST FOR TRANSFER OF ALCOHOL 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 Transfer request must meet the following conditions: � Active liquor licensee to active liquor licensee; 237-LCC2-003 of rules and regulations. Other than retailer to retailer transfer may be requested using this form plus written statement explaining the circumstances of how a non-licensee acquired liquor inventory. � Must list alcohol inventory being transferred beginning on page 3 of this request; list brand name, container size and quantity only. � Only ONE (1) transfer from location and ONE (1) transfer to location per request. Office Use Only � If business is closing, liquor license must be returned. Ready to Ratify � Administrative review will take approximately 10 to 15 days. Transferring Licensee: Class:_____ Lic #:_______________ Office Use Only Doc # 0____________ Action Code 0079 Receiving Licensee: Class:_____ Lic #:_______________ Office Use Only Doc # 0____________ Action Code 0084 _________________________________________ LICENSEE Name _________________________________________ LICENSEE Name _________________________________________ TRADE Name _________________________________________ TRADE Name _________________________________________ PREMISE Address _________________________________________ PREMISE Address ___________________________, NE __________ CITY Zip Code ___________________________, NE __________ CITY Zip Code _________________________________________ CONTACT Person _________________________________________ CONTACT Person _________________________________________ PHONE Number of Contact Person _________________________________________ PHONE Number of Contact Person _________________________________________ EMAIL Address of Contact Person _________________________________________ EMAIL Address of Contact Person Office Use Only Office Use Only Reviewed by:__________________________________________ Approved Denied Blue Agenda Date:________________ Comments: ___________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ BARCODE LABEL Office Use Only Action Code: 0003 for "received transfer request", enter in both licenses. American LegalNet, Inc. www.FormsWorkFlow.com FORM 144 Rev Jan 2017 Page 1 REASON for request: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ I acknowledge under oath that this transfer as requested complies in all respects with the requirements of the act Neb. Rev. Stat. �53-123.04 & �53-175 ____________________________________________ Signature of TRANSFER FROM licensee or officer _________________________________________ Signature of TRANSFER TO licensee or officer ____________________________________________ Print Name State of Nebraska, County of ________________________ The foregoing instrument was acknowledged before me this ________________________________________ (date) _________________________________________ Print Name State of Nebraska, County of _____________________ The foregoing instrument was acknowledged before me this _____________________________________(date) by ______________________________________________ Name of person acknowledged (Individual signing document) by ___________________________________________ Name of person acknowledged (Individual signing document) ________________________________________________ Notary Public Signature _____________________________________________ Notary Public Signature Affix Seal Affix Seal FORM 144 Rev Jan 2017 Page 2 A ten day advance period is requested in writing to produce the alternate format. American LegalNet, Inc. www.FormsWorkFlow.com Brand Name LIST OF ALCOHOL TO BE TRANSFERRED Size Qty. Brand Name Size Qty. ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ ___________________________ ________ _____ FORM 144 Rev Jan 2017 Page 3 American LegalNet, Inc. www.FormsWorkFlow.com Brand Name LIST OF ALCOHOL TO BE TRANSFERRED Size Qty. Brand Name Size Qty. ___________________________ ________ _____ ______________________