ABLE Form-Beer & Wine Application.indd

ALCOHOLIC BEVERAGE LAWS

ENFORCEMENT COMMISSION

3812 N. Santa Fe, Suite 200

Oklahoma City, OK 73118

(405) 521-3484

BEER AND WINE LICENSE APPLICATION CHECKLIST

Before completing the application packet read the information below:

•Thebuildinglocationmustbecompletelyconstructedorwithin60daysofcompletionofconstruction

 inordertoapplyforalicense.

• Both the application pages and additional items required must all be completed and provided

 forlingortheapplicationwillnotbeaccepted(onlyexception;thecerticateofcompliance

can be provided prior to license issuance).

•Theapplicationwillbereviewedandunderinvestigationuponlingofapplication.

•The license fee is due upon ling the application. We accept cash, credit card, business check,

 moneyorder,orcashier’scheckforwalk-incustomers.Mail-incustomerscansubmitthelicensefee

 bymoneyorder,cashier’scheck,orbusinesscheckonly.

•File the completed application in person or by mail at theABLE Commission, 3812 N. Santa Fe

 Avenue,Suite200,OklahomaCity,OK73118,MondaythruFriday7:30amto4:30pm.

•ContacttheABLECommissionofceat(405)521-3484orvisitourwebsiteatwww.able.ok.govfor

 questionsorgeneralinformation.

Additional items an individual Sole Proprietor must provide:

•ACerticateofLiabilityInsuranceshowingcoverageforbothbodilyinjuryandpropertydamage.

•Adeed,lease,managementagreement,orsalescontractintheindividual’sname.

•ACerticateofCompliancefromthecityorcountywherethebusinessislocatedstatingallbuilding

 codesforzoning,re,safety,andhealthareincomplianceorarenotrequired.

•ATaxStatementfromtheCountyTreasurer’sofcestatingnorealorpersonalpropertytaxesare

 owedfortheindividual.

ADDITIONAL ITEMS FOR CORPORATIONS, LIMITED LIABILITY COMPANIES,

PARTNERSHIPS AND TRIBES OR TRIBAL CORPORATIONS ARE LISTED UNDER THEIR

RESPECTIVE SECTIONS IN THE FOLLOWING APPLICATION.

Page1ABLE Form #BAW-1 Revised 3/18

ALCOHOLIC BEVERAGE LAWS

ENFORCEMENT COMMISSION

3812 N. Santa Fe, Suite 200

Oklahoma City, OK 73118

(405) 521-3484

BEER & WINE LICENSE APPLICATION

Pleasecompletetheentireform.NolicenseswillbeissuedunlesstheABLECommissionisable

toverifytheinformationprovided.TheABLECommissionmayrequestadditionalinformation

notrequestedonthisapplication.Additionalinformationmayberequiredpriortotheissuance

ofanylicense.

BEER AND WINE LICENSES AND FEES

BUSINESS OWNERSHIP INFORMATION

2.DBA Name of Location

3. Location Address

4. Mailing Address

 City

5. Business Phone Number 6. Alternate Phone Number 7. E-mail Address

 City

 County

State

Zip

BeerandWineLicense-$525

1.PrimaryBusinessatthisLocation



c

Restaurant



c

WeddingVenue



c

MotionPictureTheater

 c

EventCenter



 c

NailSalon

 c

Wine&Palette



c

CookingSchool(HigherEducation)



c

Other_________________________

8.  TypeofOwner

 

c



Individual

 

c

Partnership

 

c

LimitedPartnership

 

c

GeneralPartnership

 

c

Corporation

 

c



LimitedLiabilityCompany

 

c

Tribe

 

c

TribalCorporation/Entity

 

c

Other__________________________

9a. NameofIndividual/SoleProprietor(ifownedbyanindividual) 9b. SocialSecurityNumber

10b.FederalEmployerIdentication#10a.NameofBusinessEntity(ifPartnership,Corp.,LLCorTribe)

Page2ABLE Form #BAW-1 Revised 3/18

BUSINESS OWNERSHIP INFORMATION

12. Application Contact Person

Application Contact Address

Application Contact Phone Number Application Contact E-Mail Address

13. Name of General Manager Onsite General Manager Phone Number

11.WasPremisesPreviouslyLicensedbytheCommission

 

c

Yes

c

No

If Yes, to Whom?

 TypeofLicense

15a.Wheredidyourfundingforthisbusinessoriginate?Check and list all that apply.

INVESTMENT TYPE AMOUNT INVESTMENT TYPE AMOUNT

c

OngoingBusinessFunds

$

c

Cash/PersonalFunds

$

c

PromissoryNote

$

c

Services

$

c

Loan

$

c

Equipment

$

c

Gift

$

c

OperatingCapital

$

c

Other

$

14.Isyourbusinesslocatedwithin300feetofachurchorpublicschool?

 

c

Yes

c

No

I,_________________________________,beingdulyswornuponoathdeposesandsays:Thathe/

sheistheapplicantwhomakestheaboveandforegoingapplication,thathe/shehasreadandsigned

thesame;knowsthecontentsthereofandthatallstatementsthereincontainedaretrue.Applicant(s)

certiesthatthestatementsandrepresentationsmadehereinaretrueandcorrectandconsentsthat

ifanystatementsandrepresentationshereinarefoundtobefalseoromitted,thattheDirectormay

refusetoissuesaidlicenseormaycausesuchlicensetoberevokedforthwithatanytime.He/She

furtheragreesthathe/shehasledallappropriatepropertywiththeCountyAssessorandthatallad

valoremtaxesassessedonhis/herproperty,bothrealandpersonal,andwhereversituatedinthe

stateofOklahoma,havebeenpaid.

_________________________________________________

         SignatureofApplicant(s)

15b.Whomorwheredidtheinitialinvestmentcomefrom?ex. Bank, family owned operation, line of credit,

investment type, etc.

Page3ABLE Form #BAW-1 Revised 3/18

CORPORATE OWNERSHIP INFORMATION

CORPORATION / NON PROFIT ORGANIZATION

Corporationsmustcompletethissectionandprovidethefollowingitems:

•ACerticateofGoodStandingfromtheOklahomaSecretaryofState.Contact(405)521-4211

•ACerticateofIncorporationfromtheSecretaryofState.

•AcopyofMinutesElectingCorporateOfcers,Directors,Stockholders,andapplyingforalicense

 withABLE.

•ACerticateofLiabilityInsuranceshowingcoverageforbothbodilyinjuryandpropertydamage.

•Adeed,lease,managementagreement,orsalescontractinthenameoftheCorporation.

•ACerticateofCompliancefromthecityorcountywherethebusinessislocatedstatingallbuilding

 codesforzoning,re,safety,andhealthareincomplianceornotrequired.

•ATaxStatementfromtheCountyTreasurer’sofcestatingnorealorpersonalpropertytaxesare

 owedfortheCorporation.

• Notforprot&501(c)(3)organizationsareonlyrequiredtolistOfcers,notDirectorsorStockholders.

• OnlyStockholdersowning15%ormorearerequiredtobereportedforCorporations.

1.FederalEmployerIdenticationNumber

2.BusinessEntityName

SSNorFEI#

Drivers License No./State

Birthdate(mm/dd/yyyy)

No. of Shares



c

Ofcer 

c

Director

c

Stockholder 

c

Trustee/Beneciary



c

Ofcer 

c

Director

c

Stockholder 

c

Trustee/Beneciary



c

Ofcer 

c

Director

c

Stockholder 

c

Trustee/Beneciary

Title

Last NameFirstNameorEntityName MI

3. No. of Shares Authorized to Issue No. of Shares Issued No. of Shares Unissued

4. Service Agent Service Agent Address

Page4ABLE Form #BAW-1 Revised 3/18

CORPORATE OWNERSHIP INFORMATION (continued)

SSNorFEI#

Drivers License No./State

Birthdate(mm/dd/yyyy)

No. of Shares



c

Ofcer 

c

Director

c

Stockholder 

c

Trustee/Beneciary



c

Ofcer 

c

Director

c

Stockholder 

c

Trustee/Beneciary



c

Ofcer 

c

Director

c

Stockholder 

c

Trustee/Beneciary



c

Ofcer 

c

Director

c

Stockholder 

c

Trustee/Beneciary



c

Ofcer 

c

Director

c

Stockholder 

c

Trustee/Beneciary



c

Ofcer 

c

Director

c

Stockholder 

c

Trustee/Beneciary



c

Ofcer 

c

Director

c

Stockholder 

c

Trustee/Beneciary

Title

Last NameFirstNameorEntityName MI

IF YOU NEED MORE SPACE USE ADDITIONAL COPIES OF THIS PAGE

Page5ABLE Form #BAW-1 Revised 3/18

LIMITED LIABILITY COMPANY

LIMITED LIABILITY COMPANY OWNERSHIP INFORMATION

1.FederalEmployerIdenticationNumber

2.BusinessEntityName

SSNorFEI#

Drivers License No./State

Birthdate(mm/dd/yyyy)

% Membership or Units



c

Manager

c

Member



c

Manager

c

Member



c

Manager

c

Member

Title

Last NameFirstNameorEntityName MI

3. No. of Memberships or Units Issued 4. Member Managed or Manager Managed



c

MemberManaged

c

ManagerManaged

5. Resident Agent Name

Resident Agent Address

LimitedLiabilityCompaniesmustcompletethissectionandprovidethefollowingitems:

•ACerticateofGoodStandingfromtheOklahomaSecretaryofState.Contact(405)521-4211

•AcopyoftheArticlesofOrganizationledwiththeSecretaryofState.

•A copy of LLC OperatingAgreement including the schedule or attachment showing membership

 interest.

•ACerticateofLiabilityInsuranceshowingcoverageforbothbodilyinjuryandpropertydamage.

•Adeed,lease,managementagreement,orsalescontractinthenameoftheLLC.

•ACerticateofCompliancefromthecityorcountywherethebusinessislocatedstatingallbuilding

 codesforzoning,re,safety,andhealthareincomplianceornotrequired.

•ATaxStatementfromtheCountyTreasurer’sofcestatingnorealorpersonalpropertytaxesare

 owedfortheLLC.

Page6ABLE Form #BAW-1 Revised 3/18

LIMITED LIABILITY COMPANY OWNERSHIP INFORMATION (continued)

IF YOU NEED MORE SPACE USE ADDITIONAL COPIES OF THIS PAGE

SSNorFEI#

Drivers License No./State

Birthdate(mm/dd/yyyy)

% Membership or Units



c

Manager

c

Member



c

Manager

c

Member



c

Manager

c

Member



c

Manager

c

Member



c

Manager

c

Member



c

Manager

c

Member



c

Manager

c

Member

Title

Last NameFirstNameorEntityName MI

Page7ABLE Form #BAW-1 Revised 3/18

PARTNERSHIP INFORMATION

PARTNERSHIP

1.FederalEmployerIdenticationNumber

2.BusinessEntityName

3. Service Agent Service Agent Address

SSNorFEIN#

SSNorFEI#

Drivers License No./State

Birthdate(mm/dd/yyyy)

% of Interest



c

GeneralPartner

c

LimitedPartner



c

GeneralPartner

c

LimitedPartner



c

GeneralPartner

c

LimitedPartner



c

GeneralPartner

c

LimitedPartner

Title

Last NameFirstNameorEntityName MI

Partnerships, Limited Partnerships or General Partnerships must complete this section and

providethefollowingitems:

•ACerticateofPartnershipfromtheOklahomaSecretaryofState.Contact(405)521-4211

•AcopyofthePartnershipAgreementlistingallpartnersandtheamountofinteresteachpartnerowns.

•ACerticateofLiabilityInsuranceshowingcoverageforbothbodilyinjuryandpropertydamage.

•Adeed,lease,managementagreement,orsalescontractinthenameofthePartnership.

•ACerticateofCompliancefromthecityorcountywherethebusinessislocatedstatingallbuilding

 codesforzoning,re,safety,andhealthareincomplianceornotrequired.

•ATaxStatementfromtheCountyTreasurer’sofcestatingnorealorpersonalpropertytaxesare

 owedforeachpartner.

Page8ABLE Form #BAW-1 Revised 3/18

PARTNERSHIP INFORMATION (continued)

SSNorFEI#

SSNorFEIN#

SSNorFEI#

Drivers License No./State

Birthdate(mm/dd/yyyy)

% of Interest



c

GeneralPartner

c

LimitedPartner



c

GeneralPartner

c

LimitedPartner



c

GeneralPartner

c

LimitedPartner



c

GeneralPartner

c

LimitedPartner



c

GeneralPartner

c

LimitedPartner



c

GeneralPartner

c

LimitedPartner



c

GeneralPartner

c

LimitedPartner

Title

Last NameFirstNameorEntityName MI

IF YOU NEED MORE SPACE USE ADDITIONAL COPIES OF THIS PAGE

Page9ABLE Form #BAW-1 Revised 3/18

TRIBE/TRIBAL OWNERSHIP INFORMATION

TRIBE/TRIBAL CORPORATION

1.FederalEmployerIdenticationNumber

2.NameofTribeorTribalEntity

3. Service Agent Service Agent Address

SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)



c

TribalCommitteeOfcer

TitleLast NameFirstNameorEntityName MI

SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)



c

TribalCommitteeOfcer

TitleLast NameFirstNameorEntityName MI

SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)



c

TribalCommitteeOfcer

TitleLast NameFirstNameorEntityName MI

SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)



c

TribalCommitteeOfcer

TitleLast NameFirstNameorEntityName MI

Tribes or Tribal Corporations must complete this sectionandprovidethefollowingitems:

•YoumustsubmitacopyofanyexecutedManagementAgreements.

•YoumustsubmitacopyofthetrustdocumentordeedforthepropertyfortheTribeorCorportation.

•Youmustsubmitaletterfromthetribestatingwhetherofnottheyrequirebuildingcodeinspections

 orstatingthelocationmeetszoning,re,safety,andhealthcodes.

•Youmustsubmitaletterfromthetribestatingallrealandpersonalpropertytaxeshavebeenpaidor

 theirtaxstatusistax-exempt.

•YoumustsubmitaletterfromtheIntertribalCommissionapprovingthetribalgamingcompact.

•YoumustsubmitacopyofasignedandcompletedTribalGamingCompact.

•You must submit a copy of the tribal rules, regulations, laws, or ordinances related to alcoholic

 beverages.

Page10ABLE Form #BAW-1 Revised 3/18

TRIBE/TRIBAL OWNERSHIP INFORMATION (continued)

IF YOU NEED MORE SPACE USE ADDITIONAL COPIES OF THIS PAGE

SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)



c

TribalCommitteeOfcer

TitleLast NameFirstNameorEntityName MI

SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)



c

TribalCommitteeOfcer

TitleLast NameFirstNameorEntityName MI

SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)



c

TribalCommitteeOfcer

TitleLast NameFirstNameorEntityName MI

SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)



c

TribalCommitteeOfcer

TitleLast NameFirstNameorEntityName MI

SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)



c

TribalCommitteeOfcer

TitleLast NameFirstNameorEntityName MI

SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)



c

TribalCommitteeOfcer

TitleLast NameFirstNameorEntityName MI

SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)



c

TribalCommitteeOfcer

TitleLast NameFirstNameorEntityName MI

Page11ABLE Form #BAW-1 Revised 3/18

RESIDENTIAL ADDRESS

RESIDENT STATUS

APPLICANT

5.SocialSecurityNumber 6. Drivers License No. / State 7.PlaceofBirth(City,State,Country)

8.Sex 9. Height 10. Weight 12.EyeColor11. Hair Color

13. Home Phone 14. Business Phone

15. Email Address

16.Listresidentialaddressesfor thepast(5)years startingwiththecurrentaddress.Attachaseparate sheet

  ifnecessary.

17a.AreyouaU.S.Citizen?

 

c



Yes

c

No

17c. If “Naturalized” provide the “A” number? 17d.If“NO”whatisyourlegalstatusintheU.S.?

17b.If“Yes”,answerthefollowing

 

c

NativeBorn

c

Naturalized

4.Birthdate(mm/dd/yyyy)

3. Last Name1. First Name 2. MI

NUMBER AND STREET CITY, STATE, ZIP FROM(mm/yyyy) TO(mm/yyyy)

INDIVIDUAL PERSONAL HISTORY

MUST BE COMPLETED BY ALL APPLICANTS:

Individuals,partners,corporateofcers,directors,stockholders,LLCmanagers,LLC

members, tribal members, trustees, etc.

•Pleasecompletealleldsandanswerallquestions.

•AnyfalsestatementwilldisqualifyyouandsubjectyoutoprosecutionunderOklahomaStatelaw.

CURRENT EMPLOYMENT

18a.NameofEmployer

Title

Employer’sAddress

From(mm/yyyy) To(mm/yyyy)

17e.ProvidealldocumentssuchasVisa,ResidentAlienorEmploymentAuthorizationDocuments

Page12ABLE Form #BAW-1 Revised 3/18

INDIVIDUAL QUESTIONNAIRE

19e.Ifyouhaveanswered“Yes”to19athrough19d,listbelow

OFFENSE DATE CITY/COUNTY STATE DISPOSITION(ne,probation,incarceration)

20.Areyoupresentlyorhaveyoubeenlicensedoremployedintheliquorbusiness?

 

c

Yes

c

No

LICENSE TYPE LICENSE NUMBER WHEN LOCATION

21.Haveyoueverreceivedawarning,anoticeofviolation,suspension,neorrevocationasalicensee?

 

c

Yes

c

No

WHEN LOCATION

22.Haveyoueverbeenrefusedalicensetosell,serveordispensealcoholicbeverages?

 

c

Yes

c

No

WHEN LOCATION

23.Haveyoueverheldordoyouholdanynancialinterestinanyliquorenterprise(manufacturing,importing,

   wholesaleorretail)?

 

c

Yes

c

No

WHEN LOCATION

19b.Haveyoubeenconvictedofanycrime,violationorinfractionofanylaw?

  

c

Yes

c

No

19c.Aretherepresentlypendingagainstyouanycriminalcharges?

  

c

Yes

c

No

19a.Haveyoueverbeenconvictedof,pledguiltytoornolocontendretoafelony?

 

c

Yes

c

No

19d.Haveyoueverbeenconvictedofaviolationofanystateorfederallawrelatingtoalcoholicbeverages,or

   forfeitedanybondwhileanysuchchargewaspendingagainstyou?

  

c

Yes

c

No

24a.Isyourspouseoranyfamilymember(s)workinginanyareaoftheliquorindustry?

  

c

Yes

c

No 

24b.Ifyes,forwhom?

25a.Areyouamemberofanyboardorcommission,oranagentoranemployeeofthestateofOklahomaorany

   politicalsubdivisionthereof?(County,City,TownorSchoolDistrict)

 

c

Yes 

c

No 

25b.Ifyes,explain

Page13ABLE Form #BAW-1 Revised 3/18

INDIVIDUAL QUESTIONNAIRE (continued)

27a.Doesyourinterestresultinexerciseofcontrolover,orparticipationinthemanagementofthe

   manufactureorwholesaler’sbusinessorbusinessdecisions?

 

c

Yes 

c

No 

26a.Doyouindividually,orthelegalentitytobelicensed,haveanyright,title,lien,claimorotherinterest,

   nancialorotherwise,in,uponortothepremises,equipment,businessofanyABLECommissionLicense?

 

c

Yes 

c

No 

28a.Areyoualawenforcementofcial,apeaceofcerengaginginlawenforcementactivitiesorapersonwho

   appointslawenforcementofcials?

 

c

Yes 

c

No 

26b.Ifyes,explain

27b.Ifyes,explain

28b.Ifyes,explain

29. AreyouanemployeeoforrelatedtoanymemberoftheABLECommissionortotheDirectororAssistant

   Directorbyafnityorconsanguinitywithinthethirddegree?

 

c

Yes 

c

No 

30. Areyouajudge,districtattorneyorpublicofcialwhositsinajudicialcapacitywithjurisdictionoverthe

   OklahomaAlcoholicBeverageControlAct?

 

c

Yes 

c

No

31. AreyouanemployeeoftheOklahomaTaxCommissionengaginginauditing,enforcingorcollectingof

   alcoholicbeveragetaxes?

 

c



Yes 

c

No

I, _________________________________, under penalty of law, swear that I have read all

informationprovidedinthisdocumentandanyattachmentsandtheinformationistrueandcorrect.I

alsounderstandanyfalsestatementorrepresentationinthisapplicationcanresultinmyapplication

beingdeniedand/orcriminalchargesbeingledagainstme.IalsoauthorizetheABLECommission

tousealllegalmeanstoverifytheinformationprovided.Iauthorizeanypersonororganizationlisted

inthisapplicationtoprovideinformationaboutmetoanAgentoftheOklahomaAlcoholicBeverage

LawEnforcementCommissiononacondentialbasis,includingbankandnancialrecords,criminal

historyrecords,drivingrecords,taxrecordsandanyotherinformationrelatingtocharacterortness

foraliquorlicense.IwillimmediatelynotifytheABLECommissionifaLicensee-Wholesalerconnection

asdescribedinthequestionnaireaboveexistsoriscontemplatedinmybusiness.

_________________________________________________

Signature of Applicant

_________________________________________________

Title

Page14ABLE Form #BAW-1 Revised 3/18

LOCATION DIAGRAM

Draworattachadiagramofthelicensedpremises.Thediagramshouldincludethefollowing:

outside dimensions, rooms, doorways, bars and liquor storage areas. DO NOT SUBMIT

BLUEPRINTS

Page15ABLE Form #BAW-1 Revised 3/18

NOTICE OF INTENTION TO APPLY FOR AN

ALCOHOLIC BEVERAGE LICENSE

1. Complete in detail

2.Copytonewspaperforpublication

3.Said notice shall be publishedin not lessthan 2 columninches in alegal newspaper of

 generalcirculationinthecountyinwhichlicensedpremisesaretobelocated.

4.Thenoticewillbetwicepublished,onceeveryeight(8)daysfortwo(2)successiveweeks.

5.Submitoriginalwithapplication.

  In accordance with Title 37, Section 522 and Title 37A, Section 2-141

_______________________________________________________________________________

_______________________________________________________________________________

a/an_______________________________________________________________herebypublishes

notice of __________ intention to apply within sixty daysfrom this date to the OklahomaAlcoholic

Beverage Laws Enforcement Commission for a Beer and Wine License under

authority of and in compliance with the said Act: That _________ intend(s), if granted

such license to operate as a Beer and Wine establishment with business premises

located at _____________________________________________________________________________

in ___________________, ___________________, Oklahoma under the business name of

__________________________________________________________________________________

Datedthis_________________________dayof_______________________________,20_______

Signature of applicant(s): if partnership, all partners must sign. If corporation, an ofcer

of the corporation must sign. If limited liability company, a manager must sign. If tribe, a

tribalmembermustsign.

    ________________________________ ________________________________

Countyof___________________,Stateof___________________

Beforeme,theundersignednotarypublic,personallyappeared:

______________________________________________________________________________

to me known to be the person(s) described in and who executed the foregoing application and

acknowledgedthat_____________executedthesameas_____________freeactanddeed.

____________________________________________________________

nameandaddressofindividual,partners,limitedpartnership,corporation,limitedliabilitycompany,tribeortribalcorporation

city county

individual,partnership,limitedpartnership,corporation,limitedliabilitycompany,tribeortribalcorporation

his,her,its,their

he,she,it,they

he,she,they

NotaryPublic Mycommissionexpires

his,her,their

Page16ABLE Form #BAW-1 Revised 3/18

I do hereby declare, under penalty of perjury, that ______________________________________

did cause to be published in a legal newspaper of general circulation in the county

of ___________________ located in the city of ______________________, Oklahoma by causing

the same to be published on the _______ day of ____________________, 20________ and on

the _______ day of ____________________, 20________, a notice of intention to apply for an

ABLECommissionLicense,andthatatruecopyofsaidnoticeisattachedandmadeaparthereof.

________________________________________

Subscribedandsworntobeforemethis_______dayof____________________,20______.

____________________________________________________________

1.Attachacopyofeachrunofthepublication.

2.Submitoriginalcompletedproofofpublicationwithapplication.

3.Youmaysubmitthepublisher’safdavitforminplaceoftheaboveafdavit.

Nameoflegalnewspaper

Legalrepresentativeofthenewspaper

PROOF OF PUBLICATION

NotaryPublic Mycommissionexpires