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Get Affidavit Of Ownership Kentucky Alcoholic Beverage Form

ABC Form Ownership Aff. Revised June 2013 COMMONWEALTH OF KENTUCKY DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL 1003 Twilight Trail Frankfort Kentucky 40601-8400 502-564-4850 phone 502-564-1442 fax http //abc.ky. gov AFFIDAVIT OF OWNERSHIP Complete the following for all business proprietors partners and persons interested in the business. ABC Form Ownership Aff* Revised June 2013 COMMONWEALTH OF KENTUCKY DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL 1003 Twilight Trail Frankfort Kentucky 40601-8400 502-564-4850 phone 502-564-1442 fax http //abc*ky. gov AFFIDAVIT OF OWNERSHIP Complete the following for all business proprietors partners and persons interested in the business. List all owners officers directors partners managing members members and shareholders. Show 100 of the ownership* Make an attachment if additional space is needed* Complete Name and Address All Phone Numbers Social Security Date of Birth Title or Nature of USA List dates and Percent H Home Number Interest in this Citizen states where of W Work Business Yes / person s OwnerF Fax MM - DD - YYYY No resided in past ship 0 Other 5 years - WARNING False representations or failure to list all interested parties may result in denial or revocation of your license and be criminally punishable. I Name Title of Business or Corporate Name hereby swear and affirm under penalty of perjury that all statements and information given are true and correct to the best of my knowledge information and belief* Printed name of person signing this affidavit Signature of Affiant Subscribed and sworn before me this day of at City State Notary Public My commission expires Notary ID. gov AFFIDAVIT OF OWNERSHIP Complete the following for all business proprietors partners and persons interested in the business. List all owners officers directors partners managing members members and shareholders. Show 100 of the ownership* Make an attachment if additional space is needed* Complete Name and Address All Phone Numbers Social Security Date of Birth Title or Nature of USA List dates and Percent H Home Number Interest in this Citizen states where of W Work Business Yes / person s OwnerF Fax MM - DD - YYYY No resided in past ship 0 Other 5 years - WARNING False representations or failure to list all interested parties may result in denial or revocation of your license and be criminally punishable. List all owners officers directors partners managing members members and shareholders. Show 100 of the ownership* Make an attachment if additional space is needed* Complete Name and Address All Phone Numbers Social Security Date of Birth Title or Nature of USA List dates and Percent H Home Number Interest in this Citizen states where of W Work Business Yes / person s OwnerF Fax MM - DD - YYYY No resided in past ship 0 Other 5 years - WARNING False representations or failure to list all interested parties may result in denial or revocation of your license and be criminally punishable. I Name Title of Business or Corporate Name hereby swear and affirm under penalty of perjury that all statements and information given are true and correct to the best of my knowledge information and belief* Printed name of person signing this affidavit Signature of Affiant Subscribed and sworn before me this day of at City State Notary Public My commission expires Notary ID.

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