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Department of Alcoholic Beverage Control
State of California
CHANGE IN LICENSEE INFORMATION/LICENSED PREMISES
This form is to be used for any changes that need to be made to the licensed premises or
the licensee's information.
It is used for most of the miscellaneous license reporting
requirements, including, but not limited to:
• Reporting changes in corporations, limited liability companies, or limited
partnerships that do not require a license transfer application
• Request for Condition Modification/Removal
• Request for approval of physical changes to the licensed premises
Instructions: Complete items as appropriate. Items # 1, 4, 5, 7, 9 should be the licensee's
current information before the change. When this form is completed, it must be
submitted to the District office. Fees are non-refundable pursuant to Section 23320
B&P.
1. LICENSE NUMBER
2. RECEIPT NUMBER
3. FEE PAID
4. LICENSEE'S NAME 5. DOING BUSINESS AS (DBA) 6. DATE
7. PREMISES ADDRESS (Street number and name, city, zip code) 8. DISTRICT OFFICE
9. MAILING ADDRESS (Street number and name, city, state, zip code) 10. LICENSEE'S PHONE NUMBER
ABC USE ONLY (Items 11-14)
11. ABIS UPDATED
Yes
No
UPDATED BY
(INITIALS)
________
12. DOCUMENT EXPLAINING CHANGE ATTACHED
Yes
No
13.
ACTION OR CHANGE
a.
Corporate Change - Section 23405
b.
Limited Partnership Change - Section 23405.1
c.
Limited Liability Company Change - Section 23405.2
d.
Condition Modification/Removal - Section 23803
(Utilize ABC-333-C for approvals)
e.
Premises Expansion - Section 24072
f.
Change in Premises Designation - Rule 64.2
Premises Reduction
Physical Character Change
g.
Other
14. DETAILS OF CHANGE (ABC USE ONLY)
15. SIGNATURE (Only one signature required)
CERTIFICATION FOR SIGNATURE OF A LICENSED PRINCIPAL
I declare under penalty of perjury that I am authorized to sign for the licensed entity identified in item 1 above. I have read the foregoing and know the contents thereof.
16. SIGNATURE
1
7. PRINTED NAME AND TITLE
18. DATE
ABC USE ONLY (Items 19-24)
19. RECOMMENDATION
20. LICENSING REPRESENTATIVE SIGNATURE
21. DATE SIGNED
22. RECOMMENDATION
23. SUPERVISOR'S SIGNATURE
24. DATE SIGNED
Distribution: Original to HQ Licensing; Copy to District file
ABC-244 (rev. 09/19)
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Completed 4 May 2021

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