PLCB-1136 10/05 WAIVER/AUTHORIZATION AND LATE FILING STATEMENT PENNSYLVANIA LIQUOR CONTROL BOARD BUREAU OF LICENSING RE: Application of: License #: _________________________ LID #: _____________________ Licensee: ______________________________________________________ NAME ______________________________________________________ ADDRESS I/We do hereby acknowledge that an application for renewal of license for the term beginning _______________________________ , has been filed. The application, tax clearance as applicable, license and filing fees were submitted to the Board on or about _________________________________________ , after the expiration of the license, whereas they should have been filed not later than ___________________________ . In compliance with Section 470(a) of the Liquor Code, the applicant has submitted the additional $250.00 late filing fee. I/We waive the notice of hearing and the hearing on this matter subject to the acceptance of late filing by the Board and authorize the Board without hearing to enter a final Order or Decree on acceptance of late filing. I/We hereby state the reason for the renewal being filed after its expiration is as follows: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 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) and/or §5-504(b) and/or §7-704, that the foregoing answers and statements provided herein are true and complete to the best of my knowledge and belief. SIGNATURE TITLE SIGNATURE HOME ADDRESS TITLE HOME ADDRESS DATE SIGNED DATE SIGNED PHONE ( ) PHONE ( ) DO NOT WRITE BELOW THIS LINE American LegalNet, Inc. www.FormsWorkflow.com