NM RegulatioN aNd liceNsiNg depaRtMeNt alcoHol aNd gaMiNg diVisioN MailiNg addRess: po Box 25101 saNta fe, NM 87504-5101 pHysical addRess: toNey aNaya BuildiNg 2550 ceRRillos Road, 2Nd flooR saNta fe, NM pH: (505) 476-4875 fax: (505) 476-4595 www.Rld.state.NM.us/alcoHolaNdgaMiNg CHANGE OF STRUCTURE APPLICATION American LegalNet, Inc. www.FormsWorkFlow.com New Mexico Regulation and Licensing Department Alcohol and Gaming Division PO Box 25101 Santa Fe, NM 87504-5101 Phone: (505) 476-4875 Fax: (505) 476-4595 www.rld.state.nm.us/alcoholandg aming Rev. 05/16 CHANGE OF STRUCTURE APPLICATION 1. The non-refundable application fee of $200.00, must be enclosed or the application will be returned to you. If including additional license(s), it is $10.00 per additional license and you must include an Application Page for each License. Keep a copy of application packet for your records. 2. Pages 1, 5, and 6 of the application must be signed and notarized. 3. Note that all supporting documentation submitted must be in the name of the APPLICANT. If the applicant is a Corporation, LLC, Partnership, or Trust, the Tax Registration Certificate, Leases, Deeds, Bills of Sale, etc. must be in the name of that entity. PAGE 1 � APPLICATION, $200.00 Fee 1. Tax Registration Certificate � A copy of the New Mexico Tax Registration Certificate (CRS Identification Number) in the name of the Applicant issued by the New Mexico Taxation & Revenue Department. Applicants may obtain this documentation at any field office, or call (505) 827-0700. 2. Instrument of Conveyance (Bill of Sale, Assignment, Lease, etc.), in the name of Applicant. PAGE 3 - REQUIRED FOR CORPORATIONS/ LIMITED LIABILITY COMPANIES/ PARTNERSHIPS/ TRUSTS Full disclosure totaling 100% is required. Each individual, Officer, Director, Member, Manager, Partner and each Shareholder applying for license must complete the Personal Data Information and Affidavit Form. Each individual, Officer, Director, Member, Manager, Partner and each Shareholder who owns a 10% interest or more must be Fingerprinted. PAGE 5 - DESIGNATED RESIDENT AGENT, $50.00 Fee PAGE 6 � PERSONAL INFORMATION DATA AND AFFIDAVIT APPLICABLE LAW: NMSA �60-6B-6. Corporate licensees; limited partnership licensees; reporting. A. A corporation that holds a license issued under the Liquor Control Act [60-3A-1 NMSA 1978] shall notify the director within thirty days after the occurrence of any change in the officers, directors or holders of more than ten percent of the voting stock of the corporation, giving the names and addresses of the new officers, directors or stockholders. A corporate licensee shall also notify the director immediately of a change of agent by filing a new power of attorney. The director shall by regulation define what corporate changes, including but not limited to transfer of stock, merger and consolidation, constitute transfers of ownership of corporate licenses and shall, upon making such a determination, order appropriate compliance with the Liquor Control Act, provided that a transfer of ownership of a corporate license shall not be deemed to occur where ultimate ownership of the corporation does not change. B. A limited partnership that holds a license issued under the Liquor Control Act shall notify the director within thirty days after the occurrence of any change of general partners or of limited partners contributing ten percent or more of the total value of contributions made to the limited partnership or entitled to ten percent or more of the profits earned or other compensation by way of income paid by the limited partnership. The director shall by regulation define what limited partnership changes constitute transfers of ownership of limited partnership licenses and shall, upon making such determination, order appropriate compliance with the Liquor Control Act, provided that a transfer of ownership of a licensee that is a limited partnership shall not be deemed to occur where ultimate ownership of the limited partnership does not change. C. A legal entity that is not a corporation or limited partnership and that holds a license issued under the Liquor Control Act shall notify the director within thirty days after the occurrence of any change in the trustees, partners, owners or members of more than a ten percent interest in the entity, giving the names and addresses of the new trustees, partners or owners. The director shall by regulation define what entity changes constitute a transfer of ownership of such entity's license and shall, upon making such determination, order appropriate compliance with the Liquor Control Act, provided that a transfer of ownership of a licensee shall not be deemed to occur where there is no change in the ultimate ownership of the legal entity Please Note: The Director may require additional information or supporting documentation to complete the application. American LegalNet, Inc. www.FormsWorkFlow.com CHANGE OF STRUCTURE/CONVERSION CHECKLIST �No Hearing/Posting ***Same members converting from Corporation to LLC or from LLC to a Corporation or Sole Proprietor to LLC/Corp.*** Date Received: ____________________ License No.: ________________Type: _______________________ Expires: __________________ Applicant Name: ________________________________________ ___________________________________________________ Licensee: ________________________________________________________________________________________________ D/B/A Name: _____________________________________________________________________________________________ Location: ________________________________________________________________________________________________ Mailing Address: __________________________________________________________________________________________ REQUIREMENTS: Is License Suspended? ___Yes ___No Is it being leased? ___Yes ___No Lease Expires: ______________ Tax Hold? ___Yes ___No Any Citations pending? ___Yes ___No CHANGE MADE TO: _________________________________________________________________________________________________ _________________________________________________________________________________________________________________ PAGE 1 COMPLETED & SUBMITTED? ___Yes ___No Application fee submitted? ___Yes ___No Amount paid $_______________ Tax Registration Certificate in the name of Applicant? ___Yes ___No Comment:___________________________________ Conveyance (Bill of Sale, Assignment, etc.) submitted? ___Yes ___No Comment: ________________