Form Abc-1007 - Affidavit Of Kansas Supplier Of Alcoholic Liquor Or Cereal Malt Beverage Regarding Termination, Modification Or Alteration Of Franchise Agreement
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1Affidavit of Kansas Supplier of Alcoholic Liquor or Cereal Malt Beverage
Regarding Termination, Modification or Alteration of Franchise Agreement
Pursuant to Subsection (d) of K.S.A. 41-410
STATE OF __________________________________
)
) SS:
COUNTY OF ________________________________
)
The undersigned, a duly authorized representative of the Kansas Supplier indicated below, being of lawful age and
being first duly sworn, on his/her oath states as follows:
1. That said Supplier is conforming with K.S.A. 41-410(c) by giving notice to the Director of the Alcoholic
Beverage Control Division of the Kansas Department of Revenue of its intention to:
Terminate the franchise agreement between itself and _____________________________________________;
Kansas Distributor Name
Modify the franchise agreement between itself and _______________________________________________;
Kansas Distributor Name
Alter
the
geographic
territory
designated
in
the
franchise
agreement
between
itself
and
________________________________________; as indicated on the attached Kansas State Map (ABC-1005);
Kansas Distributor Name
2. That said termination, modification or alteration applies to the following brand(s):
3. That said termination, modification or alteration is not caused by the failure of said Distributor to comply with any
provision of the Kansas Liquor Control Act or any rules and regulations adopted pursuant thereto; and,
Further affiant sayeth not.
______________________________________________
_______________________________________________
Signature of Affiant
Name of Supplier
______________________________________________
_______________________________________________
Typed or Printed Name of Affiant
Kansas Supplier Permit Number
SUBSCRIBED AND SWORN TO before me this _______________ day of ___________________________, 20_______.
________________________________________________
Notary Public
ABC-1007 (Rev. 4.3.09)
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