Change Of Structure Application - New Mexico Regulation And Licensing Department Page 9

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AGD Stamp
Revised 5/16
New Mexico Regulation and Licensing Department | Alcohol and Gaming Division
| Page 4
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.

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