Fillable Printable Affidavit of Ownership - Kentucky
Fillable Printable Affidavit of Ownership - Kentucky
Affidavit of Ownership - Kentucky
COMMONWEALTH OF KENTUCKY
DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL
1003 Twilight Trail
Frankfort, Kentucky 40601-8400
502-564-4850 phone
502-564-1442 fax
http://abc.ky.gov
AFFIDAVIT OF OWNERSHIP
Complete the following for all business proprietors, partners, and persons interested in the business. List all owners, officers, directors, partners, managing members, members, and shareholders.
Show 100% of the ownership. Make an attachment if additional space is needed.
Complete Name and Address All Phone Numbers
H = Home
W = Work
F = Fax
0 = Other
Social Security
Number
Date of Birth
MM - DD - YYYY
Title or Nature of
Interest in this
Business
USA
Citizen
Yes /
No
List dates and
states where
person(s)
resided in past
5 years
Percent
of
Owner-
ship
- - - -
%
- - - -
%
- - - -
%
- - - -
%
- - - -
%
- - - -
%
- - - -
%
WARNING: False representations or failure to list all interested parties may result in denial or revocation of your license and be criminally punishable.
I, (Name) _________________________________________________, (Title) ______________________________ of (Business or Corporate Name) _______________________________________
hereby swear and affirm under penalty of perjury that all statements and information given are true and correct to the best of my knowledge, information, and belief.
Printed name of person signing this affidavit _____________________________________________________ Signature of Affiant ____________________________________________________
Subscribed and sworn before me this ____ day of _____________________, _________ at (City) __________________________, (State) ________________
Notary Public ________________________________________________________________
My commission expires ________________________ Notary ID# _____________________
ABC Form – Ownership Aff.
Revised June 2013
