California State Board of PharmacyDEPARTMENT OF CONSUMER AFFAIRS Fax (916) 574-8618 www.pharmacy.ca.gov Individual Financial Affidavit Please print or type All blanks must be completed; if not applicable, enter N/A Full Name: Last First Middle Telephone number ( ) Residence Address Number and Street City State Zip Code Premises Address Number and Street City State Zip Code Telephone number ( ) You must indicate one or more of the following: I am making a contribution: total amount $ cash amount $ I am contributing labor/expertise only valued at: $ I am receiving a loan: total amount $ (please attach copy of loan agreement) I am making a loan: total amount $ (please attach copy of loan agreement) I am not making a contribution in any form. SOURCE OF FUNDS USED TO FINANCE BUSINESS INSTRUCTIONS: Fully explain the source of your financial contributions (e.g. stock/bonds, real estate). If cash funds are from savings,indicate where the money was or is kept. If the source is from the sale of property, indicate what was sold, the address (if real estate), the name and address of the buyer, and the net proceeds from the sale. If a loan is involved, show the date, amount, terms, security, name and address of the lender. Describe any other sources of funds such as inheritances or gifts. Documentation may be requested. SAVINGS (Please use additional sheets if necessary) ITEM 1 ITEM 2 Financial Institution(s) Address Amount Account Number Source of savings CHECKING (Please use additional sheets if necessary) ITEM 1 ITEM 2 Financial Institution(s) Address Amount Account Number Source of checking American LegalNet, Inc. www.FormsWorkFlow.com LOANS & CREDIT APPLICATIONS FOR THIS BUSINESS (Please use additional sheets if necessary) ITEM 1 ITEM 2 Date(s) Amount(s) Term(s) Item(s) secured Security(s) Lender(s) SALE OF PROPERTY TO FINANCE THIS BUSINESS (Please use additional sheets if necessary) ITEM 1 ITEM 2 Type Location(s) Date sold Buyer Net proceeds Other source(s) Will funding be provided in any amount from an individual, partnership or corporation whose professional or vocational license has been revoked, denied or in any other manner disciplined by a regulatory board in California or any other state? Yes No If yes, please explain fully below (attach additional sheets if necessary). Attach copies of all disciplinary orders. American LegalNet, Inc. www.FormsWorkFlow.com Please read and sign below in the presence of a Notary Public. For a period of nine months from this date and pursuant to section 4207 of the Business and Professions Code, I hereby authorize the Board of Pharmacy, or any of its authorized personnel, to examine and secure copies of financial records consisting of signature cards, checking and savings accounts, note 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 occur at any time. I also authorize the Board of Pharmacy, or any of its authorized personnel, 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 understand that falsification of the information on this form may constitute grounds for denial or revocation of the license. I hereby certify under penalty of perjury under the laws of the State of California to the truth and accuracy of all statements, answers and representations made in the foregoing Individual Financial Affidavit, including all supplementary statements and I personally completed this financial affidavit. Applicant222s signature Title Date Place Attest (Notary Public) 17A-26 (Rev. 3/99) American LegalNet, Inc. www.FormsWorkFlow.com