DCPLC ­ Removal Financial Affidavit Rev 10/11 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Telephone: (860) 713-6210 Web Site: www.ct.gov/dcp REMOVAL 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 removing 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. COST TO REMOVE TO PROPOSED PREMISES: COST OF NEW BUILDING, if applicable: (If real estate is being acquired) LEASEHOLD/SECURITY DEPOSIT, if applicable: RENOVATIONS/ALTERATIONS, if applicable: FURNITURE. FIXTURES, EQUIPMENT, ETC, if applicable: OTHER EXPENSES, if applicable: (Please Specify) $ $ $ $ $ $ TOTAL FUNDS FOR ALL COSTS/EXPENSES: (add 1-6 above) $ Section B - Sources of Funds: 7. 8. 9. PERSONAL ACCOUNTS: (Savings, Checking, Certificate of Deposit-CD's) CASH ON HAND: PROMISSORY NOTES & LOANS: (Specify Other Source Types) $ $ $ TOTAL FUNDS FOR ALL SOURCES: (add 7-9 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