FORM C-801 (03/2017) MANUAL REPORTING OF NOTICE OF DEFAULT Wholesaler, Local Distributor, or Brewery / Brewpub Authorized to Sell to Retailer, Mixed Beverage or Private Club Permittee DATE: TRADENAME: OWNER: LOCATION ADDRESS: PLEASE (X) THE DESIGNATED DELIVERY PERIOD: Month: N/A 1-15 AMOUNT UNPAID: NOTICE TO RETAILER, MIXED BEVERAGE OR PRIVATE CLUB PERMITTEE Pursuant to Section 102.32 of the Texas Alcoholic Beverage Code and Rule No. 45.121, notice is hereby given that you are in default for the payment of the purchase of liquor. A Private Club or Mixed Beverage permittee who is in default for the payment of liquor may not purchase liquor products as defined in Section 1.04(5) of the Alcoholic Beverage Code from any authorizer Seller of those products until payment in full has been made to the supplier(s). PERMIT NUMBER: OR 16-31 Name of Wholesaler, Brewer, Brewpub or Local Distributor Permittee Permit / License Number Street Address City Zip Code Representative's Signature Title This Notice of Payment must be faxed or mailed to the appropriate Regional Audit Office Listed Below: Region 1 ­ 500 Chestnut Street, Ste. 1573, ABILENE, Texas 79602 ­ Fax (325) 670-9838 Region 2 ­ 2225 East Randol Mill, Ste. 200, ARLINGTON, Texas 76011 ­ Fax (817) 607-2492 Region 3 ­ 427 West 20th Street, Ste. 600, HOUSTON, Texas 77008 ­ Fax (713) 426-7979 Region 4 ­ 7700 Chevy Chase Drive, Ste. 200, AUSTIN, Texas 78752 ­ Fax (512) 451-0240 Region 5 ­ 4203 Woodcock Drive, Ste. 120, SAN ANTONIO, Texas 78228 ­ Fax (210) 731-1759 NOTE: Copy of Notice must be received by the Regional Office as least two business days prior to the scheduled Delinquent List Publication Date. American LegalNet, Inc. www.FormsWorkFlow.com