Department of Alcoholic Beverage ControlINDIVIDUAL FINANCIAL AFFIDAVIT1.NAME (Last, first, middle)2.PREMISES ADDRESS (Street number and name, city, zip code)3.MY TOTAL CONTRIBUTION IS4.MY CASH CONTRIBUTION IS$$5.SOURCE OF FUNDS (Explain fully)Source 1Source 2 (If more than one source)A.Savings/Checking/Stock Accounts Financial Institution Name Financial Institution Address Account Type Account Number Persons Authorized to Sign (Print) Amount Being Invested$$ Source of This MoneyB.Loans (e.g., loans from financial institutions, individuals, etc.) Date of Loan Amount of Loan$$ Term(s) Security Lender(s) Occupation of Lender(s)C.Sale of Property (e.g., Real estate or personal such as vehicles, jewelry, etc.) Type of Property Address of Property Date Sold Buyer's Name Net Proceeds$$D.Other Source of Funds (Inheritance, lawsuit settlements, gifts, etc.) Source(s)6.AFFIANT SIGNATURE7.DATE SIGNED8.PLACE SIGNED9.ATTEST (ABC employee or Notary Public) ABC-208-B (rev. 01-1) Refer to Form ABC-208-A instructions for who must complete this form.I understand that falsification of the information on this form may constitute grounds for denial or revocation of the license(s). For a period of 90 days from this date, I hereby authorize the Department of Alcoholic Beverage Control, or any of its officers, to examine and secure copies of financial records consisting of signature cards, checking and savings accounts, notes 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 be revoked at any time. I also authorize the Department of Alcoholic Beverage Control, or any of its officers, 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 have read all of the above and declare under penalty of perjurythateachandeverystatementistrueandcorrect. State of CaliforniaGovernor American LegalNet, Inc. www.FormsWorkFlow.com