Form Dlc4031 Ohio Department Of Commerce Division Of Liquor Control - Partnership Disclosure Form

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FOR OFFICE USE ONLY

OHIO DEPARTMENT OF COMMERCE

DIVISION OF LIQUOR CONTROL

NEW

TRANSFER

REN

6606 Tussing Road, P.O. Box 4005, Reynoldsburg, Ohio 43068-9005

Telephone: (614) 644-2360 -

PERMIT #

PARTNERSHIP DISCLOSURE FORM

(This form must accompany all applications of a partnership business entity)

Section A

Name of Partnership

DBA Name

Zip Code

City, State

Permit Premises Address

Tax Identification No. (TIN)

Township, if in Unincorporated Area

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

Social Security No. (If Individual)

Residence Address

Tax Identification No. (If Applicable)

Telephone No.

City and State

Date of Birth

Zip Code

Social Security No. (If Individual)

2) Individual Name

Residence Address

Tax Identification No. (If Applicable)

City and State

Telephone No.

Date of Birth

Zip Code

(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)

DLC4031

EOE/ADA SERVICE PROVIDER

FOR TTY USERS DIAL 1-800-750-0750

REV. 08/2015