Form PLCB-1136 "Waiver/Authorization and Late Filing Statement" - Pennsylvania

Form PLCB-1136 is a Pennsylvania Liquor Control Board form also known as the "Waiver/authorization And Late Filing Statement". The latest edition of the form was released in October 1, 2005 and is available for digital filing.

Download a PDF version of the Form PLCB-1136 down below or find it on Pennsylvania Liquor Control Board Forms website.

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Download Form PLCB-1136 "Waiver/Authorization and Late Filing Statement" - Pennsylvania

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PLCB-1136 10/05
WAIVER/AUTHORIZATION
PENNSYLVANIA
BUREAU OF LICENSING
AND LATE FILING STATEMENT
LIQUOR CONTROL BOARD
RE: Application of:
License #: _________________________ LID #: _____________________
Licensee: ______________________________________________________
NAME
______________________________________________________
ADDRESS
I/We do hereby acknowledge that an application for renewal of license for the term beginning
_______________________________ , has been filed. The application, tax clearance as applicable, license and
filing fees were submitted to the Board on or about _________________________________________ , after the
expiration of the license, whereas they should have been filed not later than ___________________________ .
In compliance with Section 470(a) of the Liquor Code, the applicant has submitted the additional $250.00
late filing fee.
I/We waive the notice of hearing and the hearing on this matter subject to the acceptance of late
filing by the Board and authorize the Board without hearing to enter a final Order or Decree on acceptance
of late filing.
I/We hereby state the reason for the renewal being filed after its expiration is as follows:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904, and 47 P.S. §4-403(h) and/or §4-436(j) and/or §5-504(b) and/or
§7-704, that the foregoing answers and statements provided herein are true and complete to the best of my knowledge and belief.
SIGNATURE
TITLE
SIGNATURE
TITLE
HOME ADDRESS
HOME ADDRESS
DATE SIGNED
DATE SIGNED
PHONE
PHONE
(
)
(
)
DO NOT WRITE BELOW THIS LINE
PLCB-1136 10/05
WAIVER/AUTHORIZATION
PENNSYLVANIA
BUREAU OF LICENSING
AND LATE FILING STATEMENT
LIQUOR CONTROL BOARD
RE: Application of:
License #: _________________________ LID #: _____________________
Licensee: ______________________________________________________
NAME
______________________________________________________
ADDRESS
I/We do hereby acknowledge that an application for renewal of license for the term beginning
_______________________________ , has been filed. The application, tax clearance as applicable, license and
filing fees were submitted to the Board on or about _________________________________________ , after the
expiration of the license, whereas they should have been filed not later than ___________________________ .
In compliance with Section 470(a) of the Liquor Code, the applicant has submitted the additional $250.00
late filing fee.
I/We waive the notice of hearing and the hearing on this matter subject to the acceptance of late
filing by the Board and authorize the Board without hearing to enter a final Order or Decree on acceptance
of late filing.
I/We hereby state the reason for the renewal being filed after its expiration is as follows:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904, and 47 P.S. §4-403(h) and/or §4-436(j) and/or §5-504(b) and/or
§7-704, that the foregoing answers and statements provided herein are true and complete to the best of my knowledge and belief.
SIGNATURE
TITLE
SIGNATURE
TITLE
HOME ADDRESS
HOME ADDRESS
DATE SIGNED
DATE SIGNED
PHONE
PHONE
(
)
(
)
DO NOT WRITE BELOW THIS LINE
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