SPOUSAL AFFIDAVIT OF NON PARTICIPATION INSERT 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 Office Use I acknowledge that I am the spouse of a liquor license holder. My signature below confirms that I will not have any interest, directly or indirectly in the operation 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, represent myself as the owner or in any way participate in the day to day operations of this business in any capacity. The penalty guideline for violation of this affidavit is cancellation of the liquor license. I acknowledge that I am the applicant of the non-participating spouse of the individual signing below. I understand that my spouse and I are responsible for compliance with the conditions set out above. If, it is determined that my spouse has violated (§53-125(13)) the commission may cancel or revoke the liquor license. ____________________________________________ Signature of NON-PARTICIPATING SPOUSE ____________________________________________ Print Name State of Nebraska, County of ________________________ The foregoing instrument was acknowledged before me this ________________________________________ (date) _________________________________________ Signature of APPLICANT _________________________________________ 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 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. American LegalNet, Inc. www.FormsWorkFlow.com FORM 116 REV NOV 2016 Page | 1