PLCB-1842 1/03 INDIVIDUAL FINANCIAL DISCLOSURE AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD 1. NAME OF APPLICANT/LICENSEE BUREAU OF LICENSING LID NO. LICENSE NO. 1. ADDRESS OF PREMISES ZIP CODE 2. TYPE OF TRANSACTION 3. LIST THE TOTAL CONSIDERATION INVOLVED IN THIS TRANSACTION TRANSFER EXT. OF PREMISES STOCK PURCHASE NEW (BREAKDOWN) A. B. C. D. E. 4. PLCB FILING/APPL. FEES LICENSE BUSINESS/GOODWILL EQUIPMENT/FIXTURES REAL ESTATE __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ F. INVENTORY G. CORP. STOCK H. CONST./RENOV. I. START UP COSTS J. OTHER TOTAL CONSIDERATION _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ INVESTORS/SOURCE OF FUNDS 4A. NAME ADDRESS __________________________________________________________ AMOUNT INVESTED/CONTRIBUTED $ _____________________________ ______________________________________________________________________________________________________________________________ PERSONAL FUNDS (LIST THE SOURCE OF INCOME FROM WHICH THESE MONIES CAME, ACCOUNT NUMBERS, & NAMES OF BANKING INSTITUTIONS) RE: 4A LOANS (LIST BOTH PRIVATE & COMMERCIAL LENDERS) RE: 4A INTEREST AMOUNT MO. PAY NO. MOS. GUARANTOR(S) AND COLLATERAL USED (EXPLAIN BELOW) OTHER SOURCES (EXPLAIN BELOW) RE: 4A 4. INVESTORS/SOURCE OF FUNDS 4B . NAME ADDRESS __________________________________________________________ AMOUNT INVESTED/CONTRIBUTED $ _____________________________ ______________________________________________________________________________________________________________________________ PERSONAL FUNDS (LIST THE SOURCE OF INCOME FROM WHICH THESE MONIES CAME, ACCOUNT NUMBERS, & NAMES OF BANKING INSTITUTIONS) RE: 4B LOANS (LIST BOTH PRIVATE & COMMERCIAL LENDERS) RE: 4B INTEREST AMOUNT NO. MOS. MO. PAY GUARANTOR(S) AND COLLATERAL USED (EXPLAIN BELOW) OTHER SOURCES (EXPLAIN BELOW) RE: 4B I hereby certify that the individual financial disclosure affidavit is true and correct and is provided under penalty of perjury, 18 PA. C.S.A. §4904 and 47 P.S. §4-403(h), and/or §4-436(j) and/or §5-504(b) and/or §7-704. AFFIANT SIGNATURE TITLE DATE PHONE NUMBER American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS QUESTION NO. 1 List the name of the applicant/licensee, the license identification number, and the license number issued by the Pennsylvania Liquor Control Board, and the address of the premises. QUESTION NO. 2 Place a check mark in the block which best describes the type of transaction being requested. QUESTION NO. 3 List the dollar amounts involved in this transaction on the lines provided, (Section 3A through 3J) then add each line to determine the total consideration involved. NOTE: 3D refers to furniture/fixtures and equipment, 3F refers to both food and alcoholic beverages, 3G (corporate stock) refers to dollar value of stock being purchased by an applicant/licensed corporation. QUESTION NO. 4 Complete one Investor/Source of Funds block for each person investing monies in this transaction. The first two investors are listed on page one of the Individual Financial Disclosure Affidavit, third and subsequent investors are listed on Attached Rider. Submit as many Riders of the Individual Financial Disclosure Affidavit as necessary to identify all investors. (Riders can be photo-copied if necessary.) NOTE: “Lenders are not considered investors and are to be listed under LOANS.” “Guarantor/Collateral Used” refers to individuals who are required to co-sign loans or encumber assets of their own for the loan to be approved. List any encumbered asset(s) used to secure the loan. “Other Sources” refers to funds derived from sources other than personal funds or loans, i.e., money being derived from the sale of real estate not yet finalized. The source of funds listed in each block No. 4 must be equal to (or be greater than) the amount invested by that investor. The total amount invested by each investor must be equal to (or greater than) the total consideration listed in block No. 3. AFFIANT SIGNATURE/DATE This Individual Financial Disclosure Affidavit must be signed and dated by the same individual(s) that signed the application submitted for this transaction. (The affiant is the person authorized by the corporation or association to sign this form.) American LegalNet, Inc. www.FormsWorkflow.com PLCB-1842 1/03 SUPPLEMENTAL RIDER COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD 4. INDIVIDUAL FINANCIAL DISCLOSURE AFFIDAVIT BUREAU OF LICENSING INVESTORS/SOURCE OF FUNDS 4_. NAME ADDRESS __________________________________________________________ AMOUNT INVESTED/CONTRIBUTED $ _____________________________ ______________________________________________________________________________________________________________________________ PERSONAL FUNDS (LIST THE SOURCE OF INCOME FROM WHICH THESE MONIES CAME, ACCOUNT NUMBERS, & NAMES OF BANKING INSTITUTIONS) RE: 4_ LOANS (LIST BOTH PRIVATE & COMMERCIAL LENDERS) RE: 4_ INTEREST AMOUNT MO. PAY NO. MOS. GUARANTOR(S) AND COLLATERAL USED (EXPLAIN BELOW) OTHER SOURCES (EXPLAIN BELOW) RE: 4_ 4. INVESTORS/SOURCE OF FUNDS 4_ . NAME ADDRESS __________________________________________________________ AMOUNT INVESTED/CONTRIBUTED $ _____________________________ ______________________________________________________________________________________________________________________________ PERSONAL FUNDS (LIST THE SOURCE OF INCOME FROM WHICH THESE MONIES CAME, ACCOUNT NUMBERS, & NAMES OF BANKING INSTITUTIONS) RE: 4_ LOANS (LIST BOTH PRIVATE & COMMERCIAL LENDERS) RE: 4_ INTEREST AMOUNT MO. PAY NO. MOS. GUARANTOR(S) AND COLLATERAL USED (EXPLAIN BELOW) OTHER SOURCES (EXPLAIN BELOW) RE: 4_ 4. INVESTORS/SOURCE OF FUNDS 4_ . NAME ADDRESS __________________________________________________________ AMOUNT INVESTED/CONTRIBUTED $ _____________________________ ______________________________________________________________________________________________________________________________ PERSONAL FUNDS (LIST THE SOURCE OF INCOME FROM WHICH THESE MONIES CAME, ACCOUNT NUMBERS, & NAMES OF BANKING INSTITUTIONS) RE: 4_ LOANS (LIST BOTH PRIVATE & COMMERCIAL LENDERS) RE: 4_ INTEREST AMOUNT MO. PAY NO. MOS. GUARANTOR(S) AND COLLATERAL USED (EXPLAIN BELOW) OTHER SOURCES (EXPLAIN BELOW) RE: 4_ American LegalNet, Inc. www.FormsWorkflow.com