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Individual Financial Affidavit ABC-208-B - California

Individual Financial Affidavit Form. This is a California form and can be used in Department Of Alcoholic Beverage Control Statewide .
 Fillable pdf Last Modified 1/10/2011
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Department of Alcoholic Beverage Control INDIVIDUAL FINANCIAL AFFIDAVIT Refer to Form ABC-208-A instructions for who must complete this form. State of California Edmund G. Brown Jr., Governor 1. NAME (Last, first, middle) 2. PREMISES ADDRESS (Street number and name, city, zip code) 3. MY TOTAL CONTRIBUTION IS 4. MY CASH CONTRIBUTION IS $ 5. SOURCE OF FUNDS (Explain fully) A. Savings/Checking/Stock Accounts Financial Institution Name Financial Institution Address Account Type Account Number Persons Authorized to Sign (Print) Amount Being Invested Source of This Money $ $ Source 1 Source 2 (If more than one source) $ B. Loans (e.g., loans from financial institutions, individuals, etc.) Date of Loan Amount of Loan Term(s) Security Lender(s) Occupation of Lender(s) C. Sale of Property (e.g., Real estate or personal such as vehicles, jewelry, etc.) Type of Property Address of Property Date Sold Buyer's Name Net Proceeds $ $ $ $ D. Other Source of Funds (Inheritance, lawsuit settlements, gifts, etc.) Source(s) I understand that falsification of the information on this form may constitute grounds for denial or revocation of the license(s). For a period of 90 days from this date, I hereby authorize the Department of Alcoholic Beverage Control, or any of its officers, to examine and secure copies of financial records consisting of signature cards, checking and savings accounts, notes and loan documents, deposit and withdrawal records, and escrow documents of my financial institution(s) or any financial records established in connection with this business. This authorization to examine records at any financial institution may be revoked at any time. I also authorize the Department of Alcoholic Beverage Control, or any of its officers, to examine and secure copies of any business records or documents established in connection with this business including, but not limited to those on file with my bookkeeper. I have read all of the above and declare under penalty of perjury that each and every statement is true and correct. 6. AFFIANT SIGNATURE 7. DATE SIGNED 8. PLACE SIGNED 9. ATTEST (ABC employee or Notary Public) ABC-208-B (rev. 01-11) American LegalNet, Inc. www.FormsWorkFlow.com
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