MANUAL REPORTING 226 AFFIDAVIT Form 809M (03/2019) (CASH LAW 226 MALT BEVERAGES) STATE OF TEXAS COUNTY OF BEFORE ME, the undersigned authority, this day personally appeared , who is a credible person, and who, after being by me duly sworn, did depose and say: THAT, a No. dated the day of , , in the (Type of instrument) (check or instrument No.) (month) (year) amount of $ was received by of , TX. (Manufacturer / Distributor / Local Distributor Permit (LP) (city) THAT, said check was received in payment of MALT BEVERAGES delivered on the day of , (month) 20, to (Retailer), permit number, located at (Street Address) , (City). That on the day of , 20, said instrument was dishonored by the drawee (Name & Address of BanK) for the following reason(s) . THAT, said dishonored was returned to (check or instrument) Manufacturer / Distributor or Local Distributor (LP) on the day of , 20, resulting in a violation of the cash law. (TABC Code 102.31) (month) (year) / Manufacturer / Distributor / Brewpub / Local Distributor (LP) License / Permit # (Notary Seal) Representative () Title Phone # SWORN TO AND SUBSCRIBED BEFORE ME, the undersigned authority this day of , 20. Notary Public in and for the State of Texas SUBMIT NOTARIZED AFFIDAVIT TO: Region 1 226 West 226 500 Chestnut Street, Ste. 1573, ABILENE, Texas 79602 226 Fax (325) 670-9838 Region 2 226 North 226 2225 East Randol Mill, Ste. 200, ARLINGTON, Texas 76011 226 Fax (817) 607-2492 Region 3 226 Southeast 226 427 West 20th Street, Ste. 600, HOUSTON, Texas 77008 226 Fax (713) 426-7979 Region 4 226 Central -7700 Chevy Chase Drive, Ste. 200, AUSTIN, Texas 78752 226 Fax (512) 451-0240 Region 5 226 South 226 4203 Woodcock Drive, Ste. 120, SAN ANTONIO, Texas 78228 226 Fax (210) 731-1759 NOTE: Affidavit to be utilized to manually report a violation of CASH LAW ONLY. American LegalNet, Inc. www.FormsWorkFlow.com