Licensing and Regulation Division PO Box 43098 Olympia WA 98504-3098 Phone: (360) 664-1600 FAX: (360) 753-2710 www.lcb.wa.gov Trade Name License Number UBI Number Affidavit of Financial Loan This affidavit serves to provide information to the Washington State Liquor and Cannabis Board regarding the review of a liquor license application (RCW 66.08.140). The below named financial institution has completed this form and given final approval of a financial loan for: Name of Person(s) or Entity Approved for Loan: Loan or Account Number: Amount of Loan: Repayment Plan (to include balloon payments and interest percentage): Collateral or Security: Date Loan was finalized: Financial Institution Name Phone Number of Representative Authorized Signature/Title Print name Date LIQ 819 7/15 American LegalNet, Inc. www.FormsWorkFlow.com