DCPLC - Financial Affidavit Rev 12/13 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Telephone: (860) 713-6210 Web Site: www.ct.gov/dcp/liquorcontrol 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. www.FormsWorkFlow.com