Partnership Disclosure Form {DLC 4031}

FOR OFFICE USE ONLY NEW PERMIT # TRANSFER REN OHIO DEPARTMENT OF COMMERCE DIVISION OF LIQUOR CONTROL 6606 Tussing Road, P.O. Box 4005, Reynoldsburg, Ohio 43068-9005 Telephone: (614) 644-2360 - http://www.com.ohio.gov/liqr PARTNERSHIP DISCLOSURE FORM Section A (This form must accompany all applications of a partnership business entity) DBA Name City, State Tax Identification No. (TIN) Zip Code Name of Partnership Permit Premises Address Township, if in Unincorporated Area Email Address: Section B General Partnership: (partnership name includes names of all partners). Uniform Partnership Law, Chapter 1775 Ohio Revised Code. Attach signed and dated copy of the general partnership agreement. Such agreement need not be filed or recorded in any public office. If the General Partnership has a fictitious name (a name different from and not including the names of all the partners), Section 1777.02 Ohio Revised Code, attach a copy of Partnership Agreement and Certificate of Fictitious Name Partnership filed with the County Recorder's Office. Limited Partnership Association: - Chapter 1783 Ohio Revised Code. Attach a copy of Partnership Agreement and Certificate of Limited Partnership Association filed with the County Recorder bearing the stamp of the County Recorder. Limited Partnership ("LP" or Ltd"): - Chapter 1782 Ohio Revised Code. Attach a copy of Partnership Agreement and a copy of Certificate of Limited Partnership filed with the County Recorder bearing the stamp of the County Recorder if partnership was formed prior to July 1, 1994. If partnership was formed after July 1, 1994 attach a copy of the Certificate of Registration filed with the Secretary of State. Limited Liability Partnership ("P.L.L.", "PLL", "L.L.P.", or "LLP"): - Chapter 1775 Ohio Revised Code. Attach signed and dated copy of Limited Liability Partnership Agreement and a copy of Certificate of Registration filed with the Secretary of State. 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 C ALL GENERAL PARTNERS LISTED BELOW MUST HAVE A BACKGROUND CHECK PERFORMED BY BCI&I AND SUBMIT A PERSONAL HISTORY BACKGROUND FORM. PLEASE READ "BACKGROUND CHECK INFORMATION" DLC4191. 1) Individual Name Residence Address City and State Zip Code 2) Individual Name Residence Address City and State Zip Code Social Security No. (If Individual) Tax Identification No. (If Applicable) Telephone No. Date of Birth Social Security No. (If Individual) Tax Identification No. (If Applicable) Telephone No. Date of Birth (PLEASE SEE REVERSE SIDE SHOULD YOU NEED ADDITIONAL SPACE TO LIST ALL PARTNERS) STATE OF OHIO, ___________________________________________ COUNTY ss, I, ___________________________________________________being first duly sworn, according to law, deposes and says that he/she is (Title) _____________________ of the __________________________________________ _____________________ ____, a business duly authorized by law to do business in the State of Ohio, and that the statements made in the forgoing affidavit are true. (Signature) ___________________________________________________ (Print Name and Corporate Title) ________________________________________________ Sworn to and subscribed in my presence this __________________ day of _____________________________________________________, ________________________. ___________________________________________________________ (Notary Public) (Notary Expiration) FOR TTY USERS DIAL 1-800-750-0750 REV. 08/2015 American LegalNet, Inc. www.FormsWorkFlow.com DLC4031 EOE/ADA SERVICE PROVIDER Page 2 DLC4031 (PARTNERSHIP DISCLOSURE FORM) SECTION C. (CONTINUED) ALL GENERAL PARTNERS LISTED BELOW MUST HAVE A BACKGROUND CHECK PERFORMED BY BCI&I AND SUBMIT A PERSONAL HISTORY BACKGROUND FORM. PLEASE READ "BACKGROUND CHECK INFORMATION" DLC4191. 3) Individual Name Residence Address City and State Zip Code 4) Individual Name Residence Address City and State Zip Code 5) Individual Name Residence Address City and State Zip Code 6) Individual Name Residence Address City and State Zip Code 7) Individual Name Residence Address City and State Zip Code 8) Individual Name Residence Address City and State Zip Code 9) Individual Name Residence Address City and State Zip Code 10) Individual Name Residence Address City and State Zip Code Social Security No. (If Individual) Tax Identification No. (If Applicable) Telephone No. Date of Birth Social Security No. (If Individual) Tax Identification No. (If Applicable) Telephone No. Date of Birth Social Security No. (If Individual) Tax Identification No. (If Applicable) Telephone No. Date of Birth Social Security No. (if Individual) Tax Identification No. (if Applicable) Telephone No. Date of Birth Social Security No. (If Individual) Tax Identification No. (If Applicable) Telephone No. Date of Birth Social Security No. (If Individual) Tax Identification No. (If Applicable) Telephone No. Date of Birth Social Security No. (If Individual) Tax Identification No. (If Applicable) Telephone No. Date of Birth Social Security No. (If Individual) Tax Identification No. (IfApplicable) Telephone No. Date of Birth American LegalNet, Inc. www.FormsWorkFlow.com