Trust

AGD Stamp New Mexico Regulation and Licensing Department | Alcohol and Gaming Division | Page 4 Revised 5/16 PO Box 25101 Santa Fe, NM 87504-5101 | Phone: (505) 476-4875 Fax: (505) 476-4595 TRUST- NMSA §60-6B-2.A(7) 1. Name of Trust:_______________________________________________________________________________________ 2. Trust Formed on: _________________________ Phone: ____________________________________ 3. Mailing Address: ___________________________________________ State: _________________ Zip: ______________ 4. Names and addresses of all Trustees and each Beneficiary of the Trust ­ full disclosure is required, for each Trustee and for each Beneficiary who has control over Trust property and income or who receives substantial and regular distributions from the Trust. If a Trustee or Beneficiary is a Corporation, Limited Liability Company or a General or Limited Partnership, complete the appropriate LLC, Corporation or Partnership page(s). LIST ALL TRUSTEES AND BENEFICIARIES % of Interest/Contribution| Title | Name | Address _____|_________________________________________________________________________________________ _____|_________________________________________________________________________________________ _____|_________________________________________________________________________________________ _____|_________________________________________________________________________________________ _____|_________________________________________________________________________________________ _____|_________________________________________________________________________________________ _____|_________________________________________________________________________________________ _____|_________________________________________________________________________________________ _____|_________________________________________________________________________________________ _____|_________________________________________________________________________________________ _____|_________________________________________________________________________________________ _____|_________________________________________________________________________________________ _____|_________________________________________________________________________________________ _____|_________________________________________________________________________________________ 5. Has this Trust ever had a liquor license in which it held any interest in any State suspended or revoked? No Yes, detailed as follows: ____________________________________________________________________________________ _______________________________________________________________________________________________ 6. List every liquor license in which this Trust owns any interest, direct or indirect: None See Attached As follows: ______________________________________________________________________________________________________ 7. Has any principal Officer, Director, Trustee or Beneficiary that holds 10% or more of this Trust ever been convicted of a felony? No Yes, detailed as follows: _________________________________________________________________ NOTE: Each individual Trustee and/or Beneficiary must submit a Personal Data Affidavit Form (Page 6), and must be Fingerprinted. All Managing Members must also be Server Certified. American LegalNet, Inc. www.FormsWorkFlow.com