plcb-2319 8/12 commonwealth of pennsylvania pennsylvania liquor control board pennsylvania application for extension of safekeeping period (see instructions on reverse) bureau of licensing page 1 of 2 the undersigned hereby applies for a one year extension of their safekeeping period 1. name of licensee license no. 2. trade name (if any) lid no. 3. address of premises (street, rural route, p.o. boX no.) (post office) (state) (Zip) safekeeping contact inforMation 4. name relationship to licensee area code phone no. 5. address (street, rural route, p.o. boX no.) (post office) (state) (Zip) 6. reason for safeKeeping: 7. what efforts are being made to reactivate the license: resolUtion (corporations and liMited liaBilitY coMpanies onlY) at a regular or special meeting held on , 20 by the applicant, it was resolved that said application be filed with the pennsylvania liquor control board, and that (name/title) and/or (name/title) is/are hereby authorized to execute said application, and any other papers required by the board. I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904 and 47 P.S. §4-403(h) and/or §4-436(j), that the foregoing answers and statements provided herein are true and complete to the best of my knowledge, information and belief. signature title name of attorney representing you in this matter, if any home address phone address signature title phone home address phone date signed email address do not Write BeloW tHis line American LegalNet, Inc. www.FormsWorkFlow.com instrUctions this application is required to extend the safekeeping period for an additional year beyond the initial 3 year period allowed by law. this application does not replace the requirement to renew and validate the license. the following information is required: 1. fee: $5,000.00 for licenses in first, second, second class a, third and fourth class counties. $2,500.00 for licenses in fifth, sixth, seventh and eighth class counties. make remittances payable to the "plcb" or "commonwealth of pennsylvania." 2. a completed application. answer all questions, sign and date the application. no changes to name and/or address of licensee can be made on this form. if there has been a change, include a brief statement to that effect. 3. The fee and application must be filed prior to the expiration of the three year safekeeping period. inforMation if you require assistance in completing this form, please call the licensing InformaTIon CenTer aT 717-783-8250. Send The ComPleTed aPPlICaTIon and fee To: PlCB, Bureau of lICenSIng, Po Box 8940, harrISBurg Pa 17105-8940 a county class designation list is attached. American LegalNet, Inc. www.FormsWorkFlow.com plcb-2319 8/12 commonwealth of pennsylvania pennsylvania liquor control board pennsylvania application for extension of safekeeping period bureau of licensing page 2 of 2 coUntY classification BY popUlation -- 2010 decennial censUs class popUlation reQUireMent coUnties 2010 popUlation fIrST SeCond SeCond a 1,500,000 or more 800,000 ­ 1,499,999 500,000 ­ 799,999 Philadelphia allegheny Bucks delaware montgomery 1,526,006 1,223,348 625,249 558,979 799,874 411,442 498,886 235,406 268,100 280,566 214,437 519,445 349,497 320,918 297,735 365,169 434,972 170,539 183,862 143,679 153,990 136,606 149,618 169,842 148,289 207,820 101,407 127,089 91,108 133,568 116,111 116,638 94,528 American LegalNet, Inc. www.FormsWorkFlow.com ThIrd 210,000 ­ 499,999 or BY ordInanCe or resolution Berks Chester Cumberland dauphin erie lackawanna lancaster lehigh luzerne northampton Westmoreland York fourTh 145,000 ­ 209,999 Beaver Butler Cambria center fayette franklin monroe Schuylkill Washington fIfTh 90,000 ­ 144,999 adams Blair lawrence lebanon lycoming mercer northumberland (continued on reverse) coUntY classification BY popUlation -- 2010 decennial censUs (cont'd) class popUlation reQUireMent coUnties 2010 popUlation SIxTh 45,000 ­ 89,999 or by ordinance or resolution armstrong Bedford Bradford Carbon clarion Clearfield clinton Columbia Crawford elk greene huntingdon indiana Jefferson mcKean mifflin Perry Pike Somerset Susquehanna Tioga Venango Warren wayne 68,941 49,762 62,622 65,249 39,988 81,642 39,238 67,295 88,765 31,946 38,686 45,913 88,880 45,200 43,450 46,682 45,969 57,369 77,742 43,356 41,981 54,984 41,815 52,822 24,636 39,702 44,947 28,276 5,085 7,716 14,845 18,267 17,457 6,428 SeVenTh 20,000 ­ 44,999 Juniata Snyder union Wyoming eighth less than 20,000 cameron forest fulton montour Potter Sullivan American LegalNet, Inc. www.FormsWorkFlow.com