SLA Form 65F (revised 02/02) STATE OF NEW YORK LIQUOR AUTHORITY STATEMENT OF FINANCES _____________________________________________________ (Name of Applicant) ____________________________ (Village) __________________________________________________ (Street Address of Premises) ___________________________________ (Town or City) _____________________________ (County) Each application for a license must be accompanied by this ‘STATEMENT OF FINANCES” properly filled out IN DUPLICATE. The total assets of all interested parties should be listed herein regardless of the amount of investment in the business. In listing bank deposits, the name and address of the bank wherein the monies are deposited and the date the account was opened should be set forth under description. Similarly, the date of acquisition should be incorporated in the description of all securities, real estates, etc. Where the applicant is a partnership or corporation, the INDIVIDUAL ASSETS OF EACH PARTNER OR STOCKHOLDER in the corporation should be listed preceded by the NAME OF THE INDIVIDUAL, PARTNER OR STOCKHOLDER. The statement of liabilities should be set forth in a similar manner showing the amount of indebtedness, the name of the creditor and the date incurred. The information contained herein will be deemed to be part of the application for license and will be considered by the State Liquor Authority in acting upon such application. 1. (a) State the amount of the total investment the applicant is making in the business for which the application is filed. 1. (a) __________________________________________ (Amount) (b) State amount to be invested in fixtures (including goodwill if this application involves a transfer of ownership); in inventory; and in other expenses. (b) _________________________________________ (Fixtures) _________________________________________ (Inventory) _________________________________________ (Other Expenses) 2. State total net worth of applicant (deduct total liabilities from total assets as set forth on the reverse side hereof). 2. 3. (a) State whether or not the applicant’s investment in said business is to be financed solely from the assets listed on the reverse side hereof. (b) If not, state amount of additional monies to be invested in the business, the source of the same and the name and address of any person who has undertaken to advance monies to the applicant to assist in financing said business and the relationship, if any, of each such person to the applicant. (Add schedule if more space is needed.) _________________________________________ (Total Net Worth) 3. (a) _________________________________________ (Answer “Yes” or “No”) (b) _________________________________________ (Amount) _________________________________________ (Source) _________________________________________ (Name) _________________________________________ (Address) _________________________________________ (Relationship) (over) American LegalNet, Inc. www.FormsWorkflow.com ASSETS Description Amount _______________________________________________________________ $ _______________________________ _______________________________________________________________ _______________________________ _______________________________________________________________ _______________________________ _______________________________________________________________ _______________________________ _______________________________________________________________ _______________________________ _______________________________________________________________ _______________________________ _______________________________________________________________ _______________________________ _______________________________________________________________ _______________________________ _______________________________________________________________ _______________________________ _______________________________________________________________ Total Assets _______________________________ $ LIABILITIES Description Amount _______________________________________________________________ $ ________________________________ _______________________________________________________________ ________________________________ _______________________________________________________________ ________________________________ _______________________________________________________________ ________________________________ _______________________________________________________________ ________________________________ _______________________________________________________________ ________________________________ _______________________________________________________________ ________________________________ _______________________________________________________________ ________________________________ Total Liabilities $ Date ___________________________________ ______________________________________ _____________________________________ Signature of Applicant, each Partner, or (if a corporation) an Authorized Officer SLA Form 65F (revised 02/02) American LegalNet, Inc. www.FormsWorkflow.com