Connecticut > Statewide > Department Of Consumer Protection > Liquor Control Division

Backers Financial Statement - Connecticut

Backers Financial Statement Form. This is a Connecticut form and can be used in Liquor Control Division Department Of Consumer Protection Statewide .
 Fillable pdf Last Modified 1/8/2015
Get this form for FREE as a print-only pdf

DCPLC - Financial Affidavit Rev 12/13 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Telephone: (860) 713-6210 Web Site: BACKER'S FINANCIAL STATEMENT Name of Backer or Authorized Representative of the Backer: Street Address: City: State: Zip Code: **Please Note: The following sections should document the expenses involved in establishing your business and the sources of the funds to pay for these expenses. The total dollar amount in Section A should equal the total dollar amount in Section B. Additional documents may be required by the Department.** Section A ­ Cost/Expenses: 1. 2. 3. 4. 5. 6. 7. PURCHASE/SALE PRICE OF YOUR BUSINESS: COST OF BUILDING: (If real estate is being transferred) LEASEHOLD/SECURITY DEPOSIT: RENOVATIONS/ALTERATIONS: EXISTING BEER, WINE, AND/OR LIQUOR INVENTORY: FURNITURE. FIXTURES, EQUIPMENT, ETC: OTHER EXPENSES: (Please Specify) $ $ $ $ $ $ $ TOTAL FUNDS FOR ALL COSTS/EXPENSES: (add 1-7 above) $ Section B - Sources of Funds: 8. 9. PERSONAL ACCOUNTS: (Savings, Checking, Certificate of Deposit-CD's) CASH ON HAND: $ $ $ 10. PROMISSORY NOTES & LOANS: (Specify Other Source Types) TOTAL FUNDS FOR ALL SOURCES: (add 8-10 above) $ I certify under penalty of law that the information provided in this financial statement is true to the best of my knowledge: Signature of Backer or Authorized Representative of Backer: X ____________________________________________________________________Date: _______________________ Printed Name of Backer or Authorized Representative: Title: American LegalNet, Inc.
Link/Embed this Document

Popular Searches

  1. default
  2. Civil Case Cover Sheet
  3. Petition for Summary Administration
  4. modification of child support
  5. claim of exemption
  6. cover sheet
  7. continuance
  8. settlement
  9. small estate affidavit
  10. proof of service by mail

Bookmark and Share