OREGON LIQUOR CONTROL COMMISSION STATEMENT OF FUNDING SOURCES Please Print or Type Each person who invests money in this licensed business must complete this form which will become a part of the permanent file. The information must be printed legibly in ink or typed. New outlet, change of ownership, change of location Not including amounts you will owe on contract, what is the approximate total amount you will put into this business to buy or start it up? (For example: advance rent payment, down payments on contracts, buying inventory, remodeling, city and licensing fees, purchasing stock in a corporation or membership interest in an LLC. Total $ OR Change to existing license (greater privilege, additional privilege, change in legal entity, extension of premises, remodel) What is the approximate total amount you will put into making the change you are requesting? (For example: buying inventory, remodeling, city and licensing fees, purchasing stock in a corporation or membership interest in an LLC.) Total $ Identify where you got your investment money. List the full name of the bank, lender, or person who loaned or gave you money. The total in this section should be equal to, or more than, the total amount listed above. _____________________________________________ $ _____________________________________________ $ _____________________________________________ $ _____________________________________________ $ Sworn Statement: I swear the above information is true, accurate and complete. I understand that the OLCC may require me to give proof of the above information and that if the information is not true, accurate or complete the OLCC may prosecute me criminally for False Swearing under ORS 162.075. The OLCC may also refuse to grant my license application or if the license is granted may act to revoke my license based on a false sworn statement. Trade Name (d.b.a.) ___________________________________________ City _______________ ____ _ _ Printed Name ______________________________________________________ ______________________ Signature_______________________________________________________ __ 1-800-452-OLCC (6522) www.oregon.gov/olcc Date ________________ (rev. 05/10) American LegalNet, Inc. www.FormsWorkFlow.com