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Source Of Funds And Certification LIQ 824-50 - Washington
| Source Of Funds And Certification Form. This is a Washington form and can be used in Financial Liquor Control Board Statewide . |
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Licensing and Regulation Division PO Box 43098 Olympia WA 98504-3098 FAX 360/664-2710 www.liq.wa.gov License No _____________________________________ Trade Name ____________________________________ UBI No ________________________________________ SOURCE OF FUNDS and CERTIFICATION Please explain carefully ALL funds as follows: (1) to get into business: (2) to change your current liquor license: or (3) money loaned or gifted to an individual applying for a liquor license. $__________CASH explain EACH source of cash such as checking, savings, or investment accounts, trust funds, sale of Property, money on hand, etc. as follows: (1) the amount of money, (2) the name of the bank or stock account and (3) the account number, (If money is withdrawn from multiple accounts, list how much money comes from each account. (4) Money kept at home must have full explanation of how it was obtained: and (5) For the sale of property write a description of the type of property sold, the address of the real property, and the sale finalization date. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ $__________CASH BORROWED Explain EACH source of cash/credit from bank loans, finance companies, credit cards, or insurance funds as follows: (1) the amount of money, (2) the name of the bank, finance/mortgage company, or credit card, and (3) the account and/or loan number. If money is withdrawn from multiple sources, list how much comes from each source. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ $__________CASH BORROWED or GIFTED FROM A PERSONAL SOURCE. State the amounts of money borrowed/gifted as well as the full name and relationship of each person from which the money came. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ $__________DEFERRED CONTRACTS (Promissory Notes). Give the name of the person, company, or bank to whom these Promissory Notes are written. __________________________________________________________________________________________ __________________________________________________________________________________________ $__________OTHER (To include landlord improvements: non-monetary contributions such as labor & equipment). __________________________________________________________________________________________ $__________GRAND TOTAL of funds listed above CERTIFICATION I CERTIFY UNDER PENALTY OF PERJURY THAT ALL ANSWERS AND STATEMENTS ARE TRUE, CORRECT AND COMPLETE. I UNDERSTAND THAT UNTRUTHFUL OR MISLEADING ANSWERS ARE CAUSE FOR REJECTION OF MY APPLICATION AND/OR REVOCATION OF ANY LICENSE GRANTED. I HEREBY AUTHORIZE INVESTIGATION OF MY CRIMINAL HISTORY, FINANCIAL RECORDS AND OTHER SOURCES AS NECESSARY FOR LICENSING. PRINT NAME______________________________________________ SIGNATURE______________________________________________ PLACE______________________________DATE_______________ LIQ 824-50-10/06 Reset Form Print Form American LegalNet, Inc. www.FormsWorkflow.com
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