Sla Form 225 008 – Fill Out and Use This PDF

STATE OF NEW YORK – LIQUOR AUTHORITY

ATTN: Refund Unit

80 South Swan Street, Suite 900

Albany, NY 12210-8002

If the licensee desires to surrender a license or permit voluntarily for cancellation and refund, if any, before the expiration date, as provided in Section 127 of the Alcoholic Beverage Control Law, fill in and sign the following petition and send to the State Liquor Authority address listed above., together with the license or permit certificate. Any false statements may subject the licensee or permittee to disciplinary proceedings and void any request for refund.

NOTE: No refund is payable unless this form is completed and the Federal Employer Identification Number (FEIN) of the licensed entity has been provided.

	PETITION FOR SURRENDER OF LICENSE
TO THE STATE LIQUOR AUTHORITY:
The undersigned individual, partnership,	corporation (CHECK ONE) petitions the Liquor Authority, under provisions of Section 127 of the Alcoholic
Beverage Control Law, to accept voluntary surrender of license (permit) certificate number ____________________which was issued to
____________________________________________ and in support of this petition makes the following statements and answers:
(Name of licensee)	YES	or	NO

1.Has the licensee or (if a partnership) any of the partners or (if a corporation) any of the officers, directors or stockholders been arrested or indicted or served with a summons for any crime or offense (except traffic infractions or violations of the Administrative Code) in the past 12 months?

2.Has any person other than reported in Question 1 above been arrested or indicted or served with a summons for any crime or

offense committed on the licensed premises or which involved the licensed business (except violations of the Administrative Code) in the past 12 months?

(If answer to either 1 or 2 above is “Yes”, attach an affidavit setting forth in each case the date thereof, crime or offense involved, the name of the defendant and disposition of the case.)

3.The undersigned petitioner further states that the said licensee will, upon the surrender of said license, cease to traffic in alcoholic beverages during the term for which said license was issued and thereafter until a new license shall be issued to said licensee.

WHEREFORE, the undersigned petitioner asks that said license be cancelled and a refund made as provided in Section 127 of the Alcoholic Beverage Control Law.

Individual and/or Partnerships complete both Sections (A)		Corporations complete both Sections (B)
(A) Individual licensee and each member of a partnership sign here and sign	│	(B) If a Corporation, sign here and sign appropriate certification below.
appropriate certification below.	│
	│
Dated _____________________________________________________	│	Dated _________________________________________________
	│
__________________________________________________________	│	Name of Corporation:
	│
__________________________________________________________	│	_______________________________________________________
	│
__________________________________________________________	│	By: ____________________________________________________
	│

(A)CERTIFICATION TO BE SIGNED AND DATED BY INDIVIDUAL AND EACH MEMBER OF PARTNERSHIP

The undersigned each for himself/herself certifies that he/she is the holder of the aforesaid license; that he/she made the foregoing petition; that he/she knows the contents thereof and the statements contained therein, and the same are true of his/her own knowledge.

Dated ______________________________________________
(Signature) of person(s) signing petition)	(Present residence address)

______________________________________________________________of___________________________________________________________________

______________________________________________________________of___________________________________________________________________

______________________________________________________________of___________________________________________________________________

(B)CERTIFICATION TO BE SIGNED AND DATED BY A CORPORATION

_________________________________________________________certifies that he/she is _________________________________________________________

(Name)

(Title)

of the _________________________________________________Corporation which is holder of this license and which made and executed this petition; that he/she signed

his/her name thereto by order of the Board of Directors of said Corporation; that he/she knows the contents thereof and the statements contained therein; and the same are true of his/her own knowledge.

Dated ____________________________________________

__________________________________________________________________of_______________________________________________________________

(Signature of officer signing petition)		(Present residence address)
Date of Surrender	__________________________________	FEIN No. ___________________________________________________________
License Serial No.	___________________________________

Please specify the address where the refund, if any, is to be mailed : ____________________________________________________________________________

SLA Form 225-008 (01/28/2011)