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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 . |
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DCPLC-Financial Rev 3/08 STATE OF CONNECTICUT Telephone: (860) 713-6210 Web Site: www.ct.gov/dcp DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Backer's Financial Statement 1. Name of backer or authorized representative of the backer: 2. Street Address: City: State: Zip code: 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. Section A. Expenses: 3. TOTAL COST OF ESTABLISHING YOUR BUSINESS: (this includes, but is not limited to, purchase price, real estate, renovations, fixtures, inventory) $ Section B. Sources of funds: 4a. Backer's funds: (i.e. funds that are the backer's and held in the form of checking, savings, securities) 4b. Loans and promissory notes: (all funds that the backer is borrowing) $ $ 4c. Other sources of funds: (specify type) TOTAL FUNDS FROM ALL SOURCES: (add 4a, 4b,& 4c 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. www.FormsWorkflow.com
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