Illinois > Statewide > Liquor Control Commission
Affidavit Of Loss Theft Or Destruction Of State Liquor License - Illinois
| Affidavit Of Loss Theft Or Destruction Of State Liquor License Form. This is a Illinois form and can be used in Liquor Control Commission Statewide . |
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DUPLICATE LICENSE FEE $12.00 FOR LICENSES UP TO AND INCLUDING $200.00 $24.00 FOR LICENSES OVER $200.00 AFFIDAVIT OF LOSS, THEFT OR DESTRUCTION OF STATE LIQUOR LICENSE STATE OF ILLINOIS County I, INSERT NAME OF AFFIANT do hereby swear or affirm that State License as a(n) CLASS OF LICENSE - RETAILER, ETC. No. of Alcoholic Liquors was issued to at INSERT NAME OF LICENSEE STREET ADDRESS OR RURAL ROUTE by the Illinois Liquor Control Commission and that the said license has been on or about DATE lost stolen destroyed (check whichever word applies) , and that I have made diligent efforts to find or recover said license, but that I have been unable to find or recover it and that it is not in my possession nor do I have any knowledge of its present whereabouts; I futher swear or affirm that this affidavit is made for the purpose of obtaining a duplicate of the above described license. **INCLUDE A COPY OF YOUR LOCAL LICENSE** SIGNATURE OF AFFIANT Subscribed and sworn to before me this day of , A.D. NOTARY PUBLIC American LegalNet, Inc. www.FormsWorkflow.com
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