Form 112 Application for Deletion to Liquor License - Nebraska

Form 112 or the "Application For Deletion To Liquor License" is a form issued by the Nebraska Liquor Control Commission.

The form was last revised in April 1, 2015 and is available for digital filing. Download an up-to-date Form 112 in PDF-format down below or look it up on the Nebraska Liquor Control Commission Forms website.

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APPLICATION FOR DELETION
Office Use
TO LIQUOR LICENSE
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046
LINCOLN, NE 68509-5046
PHONE: (402) 471-2571
FAX: (402) 471-2814
Website:
www.lcc.nebraska.gov
Application:
 Must include processing fee of $45.00 checks made payable to Nebraska Liquor Control
Commission (NLCC) or you may pay online at
www.ne.gov/go/NLCCpayport
 Must include simple hand drawn sketch showing existing licensed area and area to be deleted,
must include outside dimensions in feet (not square feet), and show direction north.
NO BLUE PRINTS
 May include approval from the local governing body; no deletion shall be approved unless
endorsed by the local governing body
 Check with your local governing body for any additional requirements that may be necessary in
making this request for deletion
LIQUOR LICENSE #__________________________________CLASS TYPE________________________
LICENSEE NAME________________________________________________________________________
TRADE NAME___________________________________________________________________________
PREMISE ADDRESS______________________________________________________________________
CITY_________________________ZIP CODE_______________COUNTY_________________________
CONTACT PERSON______________________________________________________________________
PHONE NUMBER OF CONTACT PERSON__________________________________________________
EMAIL ADDRESS OF CONTACT PERSON__________________________________________________
BARCODE
LABEL
FORM 112
REV APR 2015
Page 1 of 2
APPLICATION FOR DELETION
Office Use
TO LIQUOR LICENSE
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046
LINCOLN, NE 68509-5046
PHONE: (402) 471-2571
FAX: (402) 471-2814
Website:
www.lcc.nebraska.gov
Application:
 Must include processing fee of $45.00 checks made payable to Nebraska Liquor Control
Commission (NLCC) or you may pay online at
www.ne.gov/go/NLCCpayport
 Must include simple hand drawn sketch showing existing licensed area and area to be deleted,
must include outside dimensions in feet (not square feet), and show direction north.
NO BLUE PRINTS
 May include approval from the local governing body; no deletion shall be approved unless
endorsed by the local governing body
 Check with your local governing body for any additional requirements that may be necessary in
making this request for deletion
LIQUOR LICENSE #__________________________________CLASS TYPE________________________
LICENSEE NAME________________________________________________________________________
TRADE NAME___________________________________________________________________________
PREMISE ADDRESS______________________________________________________________________
CITY_________________________ZIP CODE_______________COUNTY_________________________
CONTACT PERSON______________________________________________________________________
PHONE NUMBER OF CONTACT PERSON__________________________________________________
EMAIL ADDRESS OF CONTACT PERSON__________________________________________________
BARCODE
LABEL
FORM 112
REV APR 2015
Page 1 of 2
1.
What is being deleted?
Explain why this area is being removed from licensed description
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
2.
Include a sketch of the area to be deleted showing:
 existing licensed area with length & width in feet
 area to be deleted with length & width in feet
 direction north
I acknowledge under oath that the premises as altered to comply in all respects with the requirements of the act.
Neb Rev Stat §53-129
________________________________________________
Signature of Licensee or Officer
State of Nebraska
County of _____________________________________ The foregoing instrument was acknowledged before me this
__________________________________________ by __________________________________________________
Date
name of person acknowledged (individual(s) signing document)
Affix Seal
__________________________________________
Notary Public signature
FORM 112
REV APR 2015
Page 2 of 2

Download Form 112 Application for Deletion to Liquor License - Nebraska

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