Amendment Application For A Change Of Beneficial Interest Or Transfer/issuance Of Stock - Massachusetts Alcoholic Beverages Control Commission Page 4

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AMENDMENT APPLICATION FOR A CHANGE OF BENEFICIAL INTEREST OR

TRANSFER/ISSUANCE OF STOCK

4. CURRENT OWNERSHIP (Before Change in Beneficial Interest)

Please list all individuals or entities with a direct or indirect, beneficial or financial interest in this license. This pertains to the current licensee (before change in

beneficial interest occurs).

Name

Title / Position

% Owned

Other Beneficial Interest

PROPOSED OWNERSHIP (After Change in Beneficial Interest)

Please list all individuals or entities with a direct or indirect, beneficial or financial interest in this license.

An individual or entity has a direct beneficial interest in a license when the individual or entity owns or controls any part of the license. For example, if John Smith

owns Smith LLC, a licensee, John Smith has a direct beneficial interest in the license.

An individual or entity has an indirect beneficial interest if the individual or entity has 1) any ownership interest in the license through an intermediary, no matter

how removed from direct ownership, 2) any form of control over part of a license no matter how attenuated, or 3) otherwise benefits in any way from the license’s

operation. For Example, Jane Doe owns Doe Holding Company Inc., which is a shareholder of Doe LLC, the license holder. Jane Doe has an indirect interest in the

license.

A. All individuals listed below are required to complete a

Beneficial Interest Contact - Individual

form.

B. All entities listed below are required to complete a

Beneficial Interest Contact - Organization

form.

C. Any individual with any ownership in this license and/or the proposed manager of record must complete a

CORI Release Form

Name

Title / Position

% Owned