Page 1 of 2 Form 2-65 (0/201) ASSIGNMENT (FOR PERFORMANCE BOND PURPOSES ONLY) 2-65 (0/201) (1) hereinafter called assignor, whose principal place of business is (2) (3) , Texa s, do (does) hereby assign, and set over the Texas Alcoholic Beverage Commission of the State of Texas, all right, title and interest of whatever nature, of assignor, in and to the insured account of assignor in the (4) evidenced by (5) in the amount of (6) $ numbered (7) Assignor agrees that this assignment carries with it the right to the insurance of the account by the (8) and includes and gives the right to the Administrator of the Texas Alcoholic Beverage Commission of the State of Texas to redeem, collect, and withdraw the full amount of such account at any time WITHOUT NOTICE TO THE ASSIGNOR. Th e condition of the obligation of this assignment is such that the permittee or licensee shall faithfully conform with the Texas Alcoholic Beverage Code and Rules of the commission. If the holder of this permit or license violates a law of the state relati ng to alcoholic beverages or a rule of the commission, the amount of the certificate of deposit shall be paid to the state. Assignor herby notifies the above named (4) of the assignment. SIGN Date HERE (Signature of Assignor) RECEIPT FOR NOTICE OF ASSIGNMENT Receipt is acknowledged to the Administrator of the Texas Alcoholic Beverage Commission of the State of Texas of written notic e of the assignment to said State of Texas of the account identified above. We have noted in our records any lien, encumbrance, hold, cla im, or obligation of the above - identified account prior to assignment to the State of Texas. We agree to make payment by mail to the State of Texas upon demand by mail in accordance with the laws applicable to this (9) . Date SIGN HERE (Signature of Bank Officer) (Title of Bank Officer) Name of Bank Address City, State, Zip Area Code & Phone No. INSTRUCTIONS (1) Name of Applicant: IF: Corporation ------------------------------------ Corporate name must be shown Partnership ------------------------------------ must b e shown Limited Partnership -------------------------- Name of limited partnership and general partner must be shown Private Club ----------------------------------- Name of the club must be shown - (If Corporation - Corporate name) Proprietorship --------- ------------------------ Name of individual must be shown Limited Liability Partnership --------------- must be shown Limited Liability Company ----------------- Name of limited liability comp any must be shown (2) Trade Name of Business (10)An initial Performance Bond in the amount of (3) Actual Business Address and City (Not Mail Address) of $2,000 is required. In the event the first bond (4) Name of Bank, association or credit union is forfeited to the Commission, a licensee or (5) Description of automatically renewable time Certificate of Deposit or Savings Account permittee must file a second bond in the amount of (6) Amount in words and figures ($2,000/$4,000/$6,000) $4,000 before a license or permit may be reinstated. (7) Number of C.D. or Savings Account In the event the second bond is forfeited to the (8) Name of U.S. Agency insuring deposit Commission, a licensee or permittee must file a (9) Bank, association or credit union third bond in the amount of $6,000 before a license or permit may be reinstated. American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Form 2-65 (0/201) THE ASSIGNMENT OF THIS CERTIFICATE OF DEPOSIT OR SAVINGS ACCOUNT PASSBOOK PROHIBITS THE BANK FROM DISPERSING THE PRINCIPAL MONIES ASSIGNED TO THE TEXAS ALCOHOLIC BEVERAGE COMMISSION UNTIL RELEASED OR DISCARDED, IN WRITING, BY THE TEXAS ALCOHOLIC BEVERAGE COMMISSION. ACKNOWLEDGMENTS No. 1 (FOR ASSIGNOR) BEFORE ME, the undersigned authority in and for said State on this day personally appeared known to me to be the person whose name is subscribed to the (Name of Assignor) foregoing instrument, and acknowledged to me that he or she executed the same, for the purposes and considerations therein expressed. Given under my hand and seal of office, this day of A.D., SIGN HERE (S E A L) Notary Public in and for the State of Texas No. 2 (FOR BANK OR SAVINGS ASSOCIATION) BEFORE ME, the undersigned authority in and for said State on this day person ally appeared known to me to be the person whose name is subscribed to the (Name of Bank Officer) foregoing instrument, and acknowledged to me that he or she executed the same as the act and deed of the surety company thereof, and for the purposes and considerations therein expressed, and in the capacity therein stated. Given under my hand and seal of office, this day of A.D., SIGN HERE (S E A L) Notary Public in and for the State of Texas NO. 1 ASSIGNOR Name of assignor (permittee/licensee) who signed the assignment must be shown. Notary public must date, sign the acknowledgment and affix notary seal. NO. 2 BANK OR SAVINGS ASSOCIATION Name of bank officer who signed the assignment must be shown. Notary Public must date sign the acknowledgment and affix notary seal. INFORMATION 1. As required under Section 11.61(23)(b - 1) , of the Texas Alcoholic Beverage Code, t his assignment form may only be used for Perfo rmance Bond purposes if located in a County with a population of 1.4 million or more ( Bexar, Dallas, Harris, and Tarrant Counties) unless you are an establishment, which holds a Food and Beverage Certificate, whose primary business is food service, and the certificate of deposit or savings account must be issued by a Texas bank, or savings institution. 2. Upon expiration of a license or permit, or its voluntary cancellation, the licensee or permittee may request (in writing) the release and return of the secur ity supporting their license or permit. 3. The release of this security will not be unreasonably withheld; however, the bank, or savings institution is not released from its obligation until they receive written notice of the release from this agency. 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