Ohio > Statewide > Department Of Commerce > Division Of Liquor Control
Application For Transfer Of Ownership Or Ownership And Location DLC 4120 - Ohio
| Application For Transfer Of Ownership Or Ownership And Location Form. This is a Ohio form and can be used in Division Of Liquor Control Department Of Commerce Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
For Questions call (614) 644-3156 Office hours - 8:00 a.m. to 5:00 p.m. Ohio Department of Commerce Division of Liquor Control 6606 Tussing Road, P.O. Box 4005 Reynoldsburg, Ohio 43068-9005 http://www.com.ohio.gov/liqr APPLICATION FOR TRANSFER OF OWNERSHIP OR OWNERSHIP & LOCATION OF ALL PERMIT CLASSES LISTED BELOW CAUTION: ALLOW 10 TO 12 WEEKS FOR PROCESSING. RETURN TO ADDRESS ABOVE A. Processing Fee of $100.00 made payable to the Division of Liquor Control (Non-Refundable) B. Application completed in its entirety, notarized and signed. Indicate "Buyer Name" as it appears on permit. C. If Individual, list Social Security Number at the right. __________________________________. D. If Partnership, you must submit a completed DLC Form 4031, along with a copy of the Partnership Agreement. E. If Corporation, you must submit a completed DLC Form 4030. F. If Limited Liability Company, you must submit a completed DLC Form 4032. G. If Court Appointed Transfer - you must submit Court documents. (See page 4 for further details). Please be advised that any social security numbers provided to the Division of Liquor Control in this application may be released to the Ohio Department of Public Safety, the Ohio Department of Taxation, the Ohio Attorney General, or to any other state or local law enforcement agency if the agency requests the social security number to conduct an investigation, implement an enforcement action, or collect taxes. Seller (Individual, Corporation, Partnership or LLC) DBA (doing business as) Buyer (Individual, Corporation, Partnership or LLC) DBA (doing business as) Premises Address Premises Address Township (if outside city limits) County: City & Zip Code Township (if outside city limits) County: City & Zip Code Mailing Address Mailing Address Telephone Number: Attorney's Name & Address Telephone Number: Attorney's Name & Address Attorney's Telephone Number: SELECT Class(es) of Permit(s) Being Transferred: C1 C2 C2X D1 D2 Seller's Permit Number Attorney's Telephone Number: A1 D-2X A1A D3 A2 D3A A3 D3X A4 D5 B1 D6 B2 D7 B3 OTHER B4 B5 ____________ SELECT Type of Transaction: SALE CONVERSION GIFT MERGER CORPORATE NAME CHANGE OTHER _______________________________ PARTNERSHIP CORPORATION LLC SELECT Type of Business: INDIVIDUAL FOR DIVISION USE ONLY Data Entry Initials: ________________ RECEIPT NUMBER: TAXING DISTRICT SELLERS NUMBER BUYERS NUMBER DLC4120 BUS. TYPE EOE/ADA SERVICE PROVIDER FEE CODE Data Entry Action: Violations: Ren Status: Proc. Fee Pd: YES ISSD YES NO PEND NO Comments/Notes: If "YES", what type _______________ BCI Fee Amount Paid: $ __________ American LegalNet, Inc. www.FormsWorkFlow.com Page 1 FOR TTY USERS DIAL ORS 1-800-750-0750 REV. 12-10 1. Do you or any partner, office holder, managing member, 5% stockholder or member, spouse, or other person involved in this permit hold or have any interest in another permit business? If YES, Give permit number & address on the line provided ______________________________________ ________________________________________________________________________________________ 2a. Have you or any partner, office holder, managing member, 5% stockholder or member, spouse, or other person involved in this permit ever been convicted of a felony or misdemeanor, including any alcohol-related offenses? If YES, attach a written explanation. 2b. If applicant is a sole proprietor or partnership, will spouse work on the permit premises? If YES, indicate spouse's full name__________________________________________________ 3. Have you or any partner, office holder, managing member, 5% stockholder or member, spouse, or other person involved in this permit ever been refused a permit, denied a renewal, or had a permit revoked from another state, by this Division, or the Liquor Commission? If YES, attach a written explanation. 4. Does applicant own the real estate on which the proposed business will be located? IF NO, return a completed signed and dated copy of your LEASE OR RENTAL CONTRACT OR Summary of Tenancy Rights (DLC4085). 5. Will the applicant be the sole owner of the business and equipment? IF NO , and the fixtures or equipment are rented, submit signed and dated copy of rental agreement. 6. Will any person, partnership, LLC, or corporation, excluding banks, building and loan associations, or the seller have ANY financial interest (such as money, loans, installment contracts, property or other interest) or share in the profits in your business or your property, real or personal? If YES, attach an affidavit with details. NOTE: Ohio Revised Code Section 4303.293 provides a criminal penalty for failure to answer this question completely and correctly. YES NO YES YES NO NO YES YES NO NO YES NO YES NO 7. If transferring C or D class permits, do you or any partner, office holder, managing member, member, stockholder, employee, spouse or any other person involved in this permit own any stock or have any interest in the business of a manufacturer or wholesale distributor of alcoholic beverages? If YES, attach a written explanation. 8. If transferring A or B class permits, do you or any partner, office holder, managing member, member, stockholder, employee, spouse or any other person involved in this permit own any stock or have any interest in the business of a retail permit holder? If YES , attach a written explanation. YES NO YES NO THE FOLLOWING MUST BE COMPLETED BY THE SELLER(S): I, ______________________________________________________, hereby authorize the Division of Liquor Control to process this application Print Name(s) _____________________________________________________________________________________________________________________ (Signature and Title) _________________________________________ (Residence Address) ___________________________ _________ ______________ ________________________ (City) (State) (Zip Code) (Area Code & Phone No.) THE FOLLOWING MUST BE COMPLETED BY THE BUYER(S): WARNING: Ohio Law provides that as a proposed buyer you could be liable as a successor of the permit holder's unpaid sales, use, and withholding tax liabilities. The Division of Liquor Control will be unable to transfer the permit until the tax and assessment matters are resolved to the satisfaction of the particular agency. The buyer should request that seller obtain a sales tax release certificate, by contacting the Ohio Department of Taxation, Sales and Use Tax Division, Release Unit. A Withholding Tax Release Certificate Request should b
|
|||||||
