Limited Liability Company And Corporate Report Of Changes (Liquor And 3.2 Beer Licenses) {DR 8177}

DR 8177 (05/97) PAGE 1 COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION 1375 SHERMAN STREET DENVER CO 80261 (303) 205-2300 21 LIMITED LIABILITY COMPANY AND CORPORATE REPORT OF CHANGES Liquor and 3.2 Beer Licenses $100 PER MEMBER FOR BACKGROUND INV. $100 PER PRINCIPLE FOR BACKGROUND INV. 2. State Tax Account Number Submit to Local Authority (Local Authority will submit to State) (2355) (2350) 1. LLC CORPORATION DO NOT WRITE IN THIS SPACE Corporate/L.L.C. Name 3. State Liquor License Number 5. Telephone Number 4. Trade Name 6. Address of Licensed Premises 7. Mailing Address if different than above City State ZIP Code City State ZIP Code 8. LIST ALL officers, directors (corporation) or Managing Members (L.L.C.). Attach a certificate of designation (good standing) and each officer, director or manager MUST FILL OUT a DR 8404-I (Individual History Record). Position Held Names of ALL Officers, Directors or Managing Members Home Address DOB Replaces 9. LIST ALL 10% (or more) Stockholders or 10% (or more) Members. All 10% (or more) stockholders and members MUST also fill out DR 8404-I (Individual History Record). Stockholders/Members owning 10% (or more) of business % Owned Home Address DOB Replaces 10. Registered Agent Address For Service OATH OF APPLICANT I declare under penalty of perjury in the second degree that this application and all attachments are true, correct, and complete to the best of my knowledge. 11. Authorized Signature Title Date REPORT OF LOCAL LICENSING AUTHORITY The foregoing changes have been received and examined by the Local Licensing Authority. 12. Local Licensing Authority For County Signature Title Town/City Date Attest Date DO NOT WRITE IN THIS SPACE ­ FOR DEPARTMENT OF REVENUE USE ONLY LIABILITY INFORMATION License Account Number Period Cash Fund TOTAL -100 (999) American LegalNet, Inc. www.FormsWorkflow.com DR 8177 PROTO (05/97) Page 2 INSTRUCTIONS LIMITED LIABILITY COMPANY AND CORPORATE REPORT OF CHANGES Do not use this form to reflect a change in partnership. If there is a change in partnership, you must file a transfer of ownership with your local licensing authority. NOTE: If you are a Limited Liability Company (LLC) check box number 2355. Enclose a check payable to the authority where this information will be filed, for $100.00 (for every person listed in the box numbered 2350 and enclose a check payable to the authority where this information will be filed, for $100.00 (for every person listed in sections 8 & 9 on the application). Attach the following documents to the Report of Changes Application: Certificate of Incorporation (or) Date stamped Articles or, if the corporation has been in existence for at least 2 years, a Certificate of Good Standing dated within the last two years Certificate of Authority (only if a foreign corporation) NOTE: If the Applicant's sole stockholder is a corporation or LLC, attach a letter designating one officer or member to be the "principal person" for the stockholder. This person MUST ALSO fill out DR 8404-I (Individual History Record). This application and all supporting documents must FIRST BE FILED WITH, AND APPROVED BY, THE LOCAL LICENSING AUTHORITY (CITY, TOWN, COUNTY). Applications will not be accepted unless all applicable questions are fully answered, all supporting documents correspond exactly with the name of the applicant. 1. List the name of the Corporation or Limited Liability Company. 2. List the State Sales Tax Number. 3. List the Applicant's State Liquor License Number. 4. List the Trade name of the business. 5. List the area code and telephone number of the business. 6. List the complete address, City, State and Zip Code, of the licensed premises. 7. List your mailing address if different than number 6 above. 8. List all officers, directors of a corporation, or all managing members of the LLC, and that persons position, home address, date of birth, and the name of the person being replaced (if applicable). 9. List all 10% (or more) stockholders or members and indicate their names, % owned, home address, date of birth, and the name of the person they purchased their stock from (if applicable). 10. List the name and address for service of the Registered Agent. 11. A person authorized to sign on behalf of the Applicant must sign the application, list their title, and the date the application was signed. 12. To be filled out by the local licensing authority only. List the name of the authority and indicate if the authority is a county, town/city. Then sign the application, list your title and attest the city/ county officials signature and date the application. American LegalNet, Inc. www.FormsWorkflow.com