STATE OF NEW JERSEY DEPARTMENT OF LAW AND PUBLIC SAFETY DIVISION OF ALCOHOLIC BEVERAGE CONTROL 140 EAST FRONT STREET, P.O. BOX 087 TRENTON, NJ 08625-0087 APPLICATION FOR SPECIAL PERMIT TO OPERATE UNDER LICENSE OF A DECEASED PERSON PENDING EXTENSION OF SUCH LICENSE TO THE EXECUTOR OR THE ADMINISTRATOR [AE] Applications must be accompanied by a fee of $50.00 payable by check or money order drawn to the order of the Division of Alcoholic Beverage Control. TYPE OR PRINT ANSWERS 1. Name to whom license is issued_____________________________ ___________________________________________________________ 2. License Number_____________________________________________ 3. Address of Licensed Premises_______________________________ ___________________________________________________________ 4. Name of Decedent___________________________________________ 5. Date of Death______________________________________________ 6. Did Decedent leave a Will? 7. Name of Executor or Administrator__________________________ ______Yes ______No ___________________________________________________________ 8. Address of Executor or Administrator_______________________ ___________________________________________________________ 9. Telephone Number of Executor or Administrator ___________________________________________________________ (Area Code) 10. Has the County Surrogate appointed the Executor or the Administrator? ______Yes ______No American LegalNet, Inc. www.FormsWorkflow.com 11. Has an application been filed with the municipality issuing the license to extend the license? _______Yes _________No 12. What date is it anticipated the municipality will extend the license to the Executor or Administrator? ___________________________________________________________ 13. Has the business been operating since the death of the licensee? _______Yes _______No STATE OF NEW JERSEY ) ) COUNTY OF ) ) _____________________________,of full age, being duly sworn EXECUTOR OR ADMINISTRATOR according to law upon his/her oath and says that the answers, statements and declarations made in the foregoing application are absolutely true in all respects. _____________________________ (Signature) Subscribed and sworn to before me this day of 20 . __________________________________________ (Signature of Officer Administering Oath) I hereby certify that the license issuing authority of this municipality has no objection to the granting of a Special Permit herein applied for and consents thereto. I further certify that the issuance of said permit is not contrary to any local ordinance, resolution, regulation or policy which would prohibit same. _____________________________ (Signature of Clerk) _____________________________ (Municipality) 7/03 American LegalNet, Inc. www.FormsWorkflow.com