For Q uestions call (614) 644-3156 Office hours - 8:00 a.m. to 5:00 p.m. Ohio Department of Commerce Division of Liquor Control 6606 Tussing Road, P.O. Box 4005 Reynoldsburg, Ohio 43068-9005 http://www.com.ohio.gov/liqr APPLICATION FOR TRANSFER OF OWNERSHIP OR OWNERSHIP & LOCATION OF ALL PERMIT CLASSES LISTED BELOW CAUTION: ALLOW 10 TO 12 WEEKS FOR PROCESSING. RETURN TO ADDRESS LISTED ABOVE FEE: $100.00 PROCESSING FEE - made payable to the Division of Liquor Control (Non-Refundable) Please be advised that any social security numbers provided to the Division of Liquor Control in this application may be released to the Ohio Department of Public Safety, the Ohio Department of Taxation, the Ohio Attorney General, or to any other state or local law enforcement agency if the agency requests the social security number to conduct an investigation, implement an enforcement action, or collect taxes. Seller (Individual, Corporation, Partnership or LLC): DBA (doing business as): Premises Address: Township (if outside city limits): City & Zip Code: Email: Mailing Address: Buyer (Individual, Corporation, Partnership or LLC): DBA (doing business as): Premises Address: Township (if outside city limits): City & Zip Code: Email: Mailing Address: County: County: Phone Number: Attorney's Name & Address: Phone Number: Attorney's Name & Address: Attorney's Telephone Number: SELECT Class(es) of Permit(s) Being Transferred: C1 C2 C2X D1 D2 Seller's Permit Number: Attorney's Telephone Number: A2 A3 D3X A4 D5 B1 D6 B2 D7 B3 OTHER B4 B5 A1 D-2X A1A D3 D3A ____________ MERGER SELECT Type of Transaction: CORPORATE NAME CHANGE SALE CONVERSION GIFT OTHER____________________________________________________________ SELECT Type of Business: INDIVIDUAL If Individual, list Social Security Number: __________________________________ CORPORATION LLC YES NO PARTNERSHIP If you answered "YES," you must submit Form DLC4244 (See page 4 of this form for further TREX information). Data Entry Action: Violations: FEE CODE Is this an Economic Development (TREX) Transfer? FOR DIVISION USE ONLY Data Entry Initials: ________________ RECEIPT NUMBER: TAXING DISTRICT SELLERS NUMBER BUYERS NUMBER BUS. TYPE Comments/Notes: NO PEND NO YES ISSD YES If "YES", what type _______________ Ren Status: Proc. Fee Pd: BCI Fee Amount Paid: $ __________ DLC4120 EOE/ADA SERVICE PROVIDER Page 1 FOR TTY USERS DIAL ORS 1-800-750-0750 Rev. 07/2013 American LegalNet, Inc. www.FormsWorkFlow.com 1. Do you or any partner, office holder, managing member, 5% stockholder or member, spouse, or other person involved in this permit hold or have any interest in another permit business? If YES, Give permit number & address on the line provided ______________________________________ ________________________________________________________________________________________ 2a. Have you or any partner, office holder, managing member, 5% stockholder or member, spouse, or other person involved in this permit ever been convicted of a felony or misdemeanor, including any alcohol-related offenses? If YES, attach a written explanation. 2b. If applicant is a sole proprietor or partnership, will spouse work on the permit premises? If YES, indicate spouse's full name__________________________________________________ 3. Have you or any partner, office holder, managing member, 5% stockholder or member, spouse, or other person involved in this permit ever been refused a permit, denied a renewal, or had a permit revoked from another state, by this Division, or the Liquor Commission? If YES, attach a written explanation. 4. Does applicant own the real estate on which the proposed business will be located? If NO, submit a signed and dated copy of your LEASE, RENTAL CONTRACT, OR DLC 4085 Summary of Tenancy Rights Form. 5. Will the applicant be the sole owner of the fixtures and equipment? If NO, submit a signed and dated copy of the rental agreement for the fixtures and equipment. 6. Will any person, partnership, LLC, or corporation, excluding banks, building and loan associations, or the seller have ANY financial interest (such as money, loans, installment contracts, property or other interest) or share in the profits in your business or your property, real or personal? If YES, attach a written explanation. NOTE: Ohio Revised Code Section 4303.293 provides a criminal penalty for failure to answer this question completely and correctly. YES NO YES YES NO NO YES YES NO NO YES NO YES NO 7. If transferring C or D class permits, do you or any partner, office holder, managing member, member, stockholder, employee, spouse or any other person involved in this permit own any stock or have any interest in the business of a manufacturer or wholesale distributor of alcoholic beverages? If YES, attach a written explanation. 8. If transferring A or B class permits, do you or any partner, office holder, managing member, member, stockholder, employee, spouse or any other person involved in this permit own any stock or have any interest in the business of a retail permit holder? If YES , attach a written explanation. YES NO YES NO THE FOLLOWING MUST BE COMPLETED BY THE SELLER(S): I, ______________________________________________________, hereby authorize the Division of Liquor Control to process this application _____________________________________________________________________________________________________________________ (Signature and Title) Print Name(s) _________________________________________ (Residence Address) ___________________________ _________ ______________ ________________________ (City) (State) (Zip Code) (Area Code & Phone No.) THE FOLLOWING MUST BE COMPLETED BY THE BUYER(S): WARNING: Ohio Law provides that as a proposed buyer you could be liable as a successor of the permit holder's unpaid sales, use, and withholding tax liabilities. The Division of Liquor Control will be unable to transfer the permit until the tax and assessment matters are resolved to the satisfaction of the particular agency. The buyer should request that seller obtain a sales tax release certificate, by contacting the Ohio Department of Taxation, Sales and Use Tax Division, Release Unit. A Withholding Tax Release Certificate Request should be made by contacting the Ohio Department of Taxation, Withholding Tax Division, Business Billing Unit. Also, the current permit holder may still owe Unemployment Compensation payments. To discuss these possible liabilities, you should contact the Ohio Department of Job