Fillable STATE OF KANSAS MANAGEMENT SERVICES INFORMATION (Kansas Department of Revenue)

Fill Online, Printable, Fillable, Blank STATE OF KANSAS MANAGEMENT SERVICES INFORMATION (Kansas Department of Revenue) Form

Use Fill to complete blank online KANSAS DEPARTMENT OF REVENUE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

STATE OF KANSAS MANAGEMENT SERVICES INFORMATION (Kansas Department of Revenue)

On average this form takes 33 minutes to complete

The STATE OF KANSAS MANAGEMENT SERVICES INFORMATION (Kansas Department of Revenue) form is 2 pages long and contains:

  • 2 signatures
  • 22 check-boxes
  • 112 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Kansas Department of Revenue forms online.

BROWSE KANSAS DEPARTMENT OF REVENUE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
A
LCOHOLIC BEVERAGE CONTROL
109 SW 9
th
STREET
P.O. BOX 3506
T
OPEKA KS 66601-3506
STATE OF KANSAS
DEPARTMENT OF REVENUE
P
HONE: 785-296-7015
F
AX: 785-296-7185
www.ksrevenue.org/abc.html
MANAGEMENT SERVICES INFORMATION
SECTION 1 – LICENSEE INFORMATION
FEIN
Licensee DBA Name License Number
Location Street Address City State County Zip Code
SECTION 2 – MANAGEMENT SERVICES INFORMATION
Name of Person/Entity Providing Management/Operational Services FEIN
Contact Person Daytime Phone Number
The following information must be provided on all owners, officers, shareholders, stockholders, copartners and/or trustees of the entity who will perform
management services for the retail liquor licensee, AND the spouses of all submitted persons (attach additional pages as necessary). The percentages of
ownership must total 100%.
SECTION 3 – MANAGEMENT SERVICES OWNERSHIP INFORMATION
Last Name First Name Middle Name Gender Date of Birth
Social Security Number Driver’s License Number DL State % Ownership
Current Residential Address City State County Zip Code Daytime Phone
Marital Status:
☐
Married (complete spousal information)
☐
Single
☐
☐
☐
☐
E-mail Address
Spousal Information
Last Name First Name Middle Name Gender Date of Birth
Social Security Number Driver’s License Number DL State % Ownership
Current Residential Address City State County Zip Code Daytime Phone
Last Name First Name Mi
ddle Name Gender Date of Birth
Social Security Number Driver’s License Number DL State % Ownership
Current Residential Address City State County Zip Code Daytime Phone
Marital Status:
Married (complete spousal information)
Single
E-mail Address
Spousal Information
Last Name First Name Middle Name Gender Date of Birth
Social Security Number Driver’s License Number DL State % Ownership
Current Residential Address City State County Zip Code Daytime Phone
Last Name First Nam
e Middle Name Gender Date of Birth
Social Security Number Driver’s License Number DL State % Ownership
Current Residential Address City State County Zip Code Daytime Phone
Marital Status:
Married (complete spousal information)
Single
E-mail Address
Spousal Information
Last Name First Name Middle Name Gender Date of Birth
Social Security Number Driver’s License Number DL State % Ownership
Current Residential Address City State County Zip Code Daytime Phone
ABC-807 (Rev. 07/18) Page 1 of 2
STATE OF KANSAS
A
LCOHOLIC BEVERAGE CONTROL
109 SW 9
th
STREET
P.O. BOX 3506
T
OPEKA KS 66601-3506
D
EPARTMENT OF REVENUE
PHONE: 785-296-7015
F
AX: 785-296-7185
www.ksrevenue.org/abc.html
FEIN
SECTION 4 – BACKGROUND QUALIFICATIONS
If the answer to any question is yes, provide explanation on separate page and attach to the form.
1. Has any person listed in Section 3 been convicted of a felony in Kansas, in any other state, or under federal law?
☐
Yes
☐
No
2. Has any person listed in Section 3 been convicted of a morals charge (prostitution; procuring any person; solicitation of a child
under 18 for immoral act involving sex; possession or sale of narcotics, marijuana, amphetamines or barbiturates; rape; incest;
gambling; adultery; or bigamy) in Kansas or any other state?
☐
Yes
☐
No
3. Has any person listed in Section 3 had an alcoholic liquor or cereal malt beverage license revoked in Kansas or in any state?
☐
Yes
☐
No
4. Is any person listed in Section 3 currently a law enforcement officer or non-elected official who supervises or appoints any law
enforcement officer?
☐
Yes
☐
No
5. Does any person listed in Section 3 have an ownership interest in any other business licensed to sell alcoholic liquor or cereal malt
beverage in Kansas or any other state?
☐
Yes
☐
No
☐
☐
☐
☐
☐
☐
If so, please provide license number and state of issue.
License Number: State:
6. Does any person listed in Section 3 not meet the Kansas residency requirement for the type of license applied for?
(Class A & B Club, Drinking Establishment – 1 year; Farm Winery, Microbrewery or Microdistillery – 1 year;
Retailer – 4 years; Manufacturer – 5 years)
Yes No
7. Is any person listed in Sections 3 not a US Citizen?
Yes No
If yes, explain:
SECTION 5 – TAX CLEARANCE
Has the applicant obtained their Tax Clearance? Yes No
*If yes, enter your Tax Clearance confirmation number:
**If no, you must request your Tax Clearance certificate.
To obtain your Tax Clearance, go to http://www.ksrevenue.org/taxclearance.html
Under penalties of perjury, I declare the information contained in this document a true, accurate and complete disclosure of information.
Licensee Signature Date
Management Services Signature Date
ABC-807 (Rev. 07/18) Page 2 of 2
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

STATE OF KANSAS MANAGEMENT SERVICES INFORMATION (Kansas Department of Revenue)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 24 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document