Ohio > Statewide > Department Of Commerce > Division Of Liquor Control
Application For Change Of Corporate Stock Ownership DLC 4158 - Ohio
| Application For Change Of Corporate Stock Ownership Form. This is a Ohio form and can be used in Division Of Liquor Control Department Of Commerce Statewide . |
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For Questions call (614) 644-3162 Office Hours 8:00 a.m. - 5:00 p.m. Ohio Department of Commerce - Division of Liquor Control 6606 Tussing Road, Reynoldsburg, Ohio 43068-9005 http://www.com.ohio.gov/liqr APPLICATION FOR CHANGE OF CORPORATE STOCK OWNERSHIP PROCESSING FEE $100.00 CAUTION: ALLOW 10 TO 12 WEEKS FOR PROCESSING PERMIT HOLDER REQUESTS APPROVAL OF THE DIVISION OF LIQUOR CONTROL OF THE FOLLOWING TRANSFER(S) OF STOCK Permit Holder Name Liquor Permit Number(s) Permit Premises Address Attorney's Name, Address and Telephone Number (If represented) Is Stock Traded on a National Exchange? YES NO If YES, give Name of Exchange and Symbol 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. SECTION A: PREVIOUS 5% OR MORE STOCKHOLDERS Name 1) 2) 3) 4) 5) SECTION B: REVISED 5% OR MORE STOCKHOLDERS Name 1) 2) 3) 4) 5) Number of Shares Issued For Stock Transfer Only (NOT Percentages) DATE OF BIRTH Social Security Number/FTI# Number of Shares Issued For Stock Transfer Only (NOT Percentages) DATE OF BIRTH Social Security Number/FTI# NOTE: If any Stockholder is a business entity, that entity must list it's federal tax identification number (FTI #) above. TOTAL NUMBER OF SHARES ISSUED LIST THE TOP FOUR OFFICERS OF THE CAPTIONED CORPORATION. IF AN OFFICE IS NOT HELD, PLEASE INDICATE BY WRITING "NONE" Social Security Number Date Of Birth 1) CEO/President 2) Vice-President 3) Secretary 4) Treasurer DLC4158 EOE/ADA SERVICE PROVIDER FOR TTY USERS DIAL ORS 1-800-750-0750 REV. 10-2010 American LegalNet, Inc. www.FormsWorkFlow.com THE FOLLOWING MUST BE COMPLETED BY ANY OF THE REVISED 5% OR MORE SHAREHOLDERS: 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 _______________________________________ _______________________________________________________________________________________ 2. 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. 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. If you hold C or D permits, do you or any partner, office holder, managing member, member, stockholder, employee, spouse, or 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. 5. If you hold A or B permits, do you or any partner, office holder, managing member, member, stockholder, employee, spouse, or 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 YES NO YES NO YES NO DELIBERATE MISREPRESENTATION OF ANY OF THE INFORMATION ON THIS APPLICATION CAN RESULT IN THE DIVISION'S REFUSING TO APPROVE THIS APPLICATION. THE FOLLOWING MUST BE COMPLETED BY ANY OF THE REVISED 5% OR MORE SHAREHOLDERS: State of Ohio, _______________________________County, ss I, ____________________________________________________________________, being first duly sworn, according to law, depose and say (Please Print) that the statements and answers made in the foregoing application are true. ___________________________________________________________________________ (Signature of Individual, Partner, Officer, Managing Member, or 5% or more Stockholder or Member) _____________________ (Title) _______________ (Date) _____________________________________ (Residence Address) ______________________ (City) _____________ (State) ___________ (Zip Code) ______________________ (Area Code & Phone Number) (To be completed by Notary Public) Sworn to before me and subscribed in my presence this ______________day of _____________________________________, 20 _____________. ________________________________________ (Notary Public) _______________ (Notary Expiration) Page 2 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR FILING CHANGE OF "CORPORATE STOCK OWNERSHIP" APPLICATION A fee of $100.00 is required with all Stock Ownership Applications A "CHANGE OF CORPORATE STOCK OWNERSHIP" APPLICATION MUST BE FILED WHEN: An individual, a partnership or another business entity becomes a 5% or more stockholder of the permit holder; A 5% or more stockholder acquires additional shares from any other stockholder; A 5% or more stockholder loses any number of shares; A 5% or more stockholder ceases to be a 5% or more stockholder; A less than 5% stockholder acquires enough shares to become a 5% or more stockholder; An officer changes in a corporate permit holder; There is a change in the stockholder who holds the greatest number of shares (the plurality) in the corporation. Example: "A" holds a 45 shares "B" holds a 25 shares "C" holds a 30 shares "A" holds the plurality. If "A" sells 20 shares to "C", "C" would now have the plurality of 50 shares. No one holds a majority of the shares. All changes of 5% or more stockholders or number of shares held must be reported to the Division as soon as the change is contemplated. If there is a change in the number of shares only, due to a stock split or stock dividend, filing of this application is not required. However, such change in the number of shares held must be reported to the Division together with an affidavit and DLC 4030 over the signature of the Secretary of the corporation certifying such fact and the date of its occurrence. Under "PREVIOUS 5% OR MORE STOCKHOLDERS" print names of present 5% or more stockholders and number of shares owned as listed on Division records. Under "REVISED 5% OR MORE STOCKHOLDERS" print names of the proposed new 5% or more st
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