Financial Verification Worksheet Form. This is a Ohio form and can be use in Department Of Commerce Statewide.
Tags: Financial Verification Worksheet, DLC 4096, Ohio Statewide, Department Of Commerce
OHIO DEPARTMENT OF COMMERCE - DIVISION OF LIQUOR CONTROL 6606 TUSSING ROAD, P.O. BOX 4005 - REYNOLDSBURG, OHIO 43068-9005 http://www.com.state.oh.us FINANCIAL VERIFICATION WORKSHEET FOR OFFICE USE ONLY THE TOTAL COST TO BUY AND/OR SET UP THIS BUSINESS IS $ ____________________. (This amount should coincide with the amount listed in the purchase agreement if buying an existing business, unless excess funds are needed for remodeling. Additional operating revenue, etc. If so, explain by attaching an additional page.) NEW TRANSFER STOCK PERMIT # SOURCE OF FUNDS: Indicate which of the following is applicable by noting the appropriate amounts in the spaces provided and by ATTACHING THE APPROPRIATE DOCUMENTS AS REQUESTED. FINANCIAL VERIFICATION IS NOT COMPLETE WITHOUT THE REQUIRED ATTACHMENTS. AMOUNT SOURCE OF FUNDS DOCUMENTS TO BE SUBMITTED WITH APPLICATION $ LOAN(S) FROM A FINANCIAL INSTITUTION Attach signed copy of loan agreement, letter of commitment, or letter of credit to this page. $ LAND CONTRACT Attach signed copy of agreement to this page $ PROMISSORY NOTE HELD BY SELLER Attach signed copy of note to this page $ ASSUMPTION OF SELLER’S DEBT(S) Attach copy of agreement, signed by buyer and seller, listing creditors, account numbers of debts assumed, and amount still outstanding. $ LOAN FROM AN INDIVIDUAL OR Attach statement, notarized by a notary public, over the OTHER THIRD PARTY, WHOSE NAME signature of applicant, relating the details of the loan and WILL NOT APPEAR ON THE PERMIT stating what, if any, interest the money lender has in the permit business. PERSONAL FUNDS OF APPLICANT Attach letter of verification from institution to this ACCUMULATED AT FINANCIAL page, stating amount in account, and name of account INSTITUTION holder. $ $ PERSONAL FUNDS OF APPLICANT NOT DEPOSITED IN FINANCIAL INSTITUTION Attach statement, notarized by a notary public, over the signature of applicant, stating the source of funds, amount of funds, and location. $ CORPORATE FUNDS ON HAND Attach letter of verification from financial institution stating company name and amount in account $ OTHER Attach statement, notarized by a notary public, over the signature of applicant, relating the source of funds and supporting documents to verify the source listing amounts. $ TOTAL FUNDS NOTE TO APPLICANTS FOR NEW PERMITS ONLY: If you are applying for a NEW permit for a business that you have operated in excess of one (1) year, please submit a notarized affidavit to that effect. In such a case, no further verification will be needed. THIS DOES NOT APPLY TO TRANSFERS OF OWNERSHIP, OR TO BUSINESSES IN OPERATION LESS THAN ONE YEAR. THIS WORK SHEET HAS BEEN DEVISED AS AN AID TO APPLICANTS IN COMPLETING THE FINANCIAL VERIFICATION REQUIRED FOR THEIR APPLICATION FOR A LIQUOR PERMIT. THIS SHEET ALONE, DOES NOT CONSTITUTE FINANCIAL VERIFICATION. ATTACHMENTS ARE REQUIRED. DLC4096 FOR TTY USERS DIAL ORS 1-800-750-0750 EOE/ADA SERVICE PROVIDER REV. 4-03 American LegalNet, Inc. www.FormsWorkflow.com