Liquor Control Board Licensing and Regulation PO Box 43098 Olympia WA 98504-3098 Phone: (360) 664-1600 Fax: (360) 753-2710 Liquor License No. Financial/Source of Funds Statement for Person or Entity Loaning, Gifting, or Investing Money Please type or print clearly in dark ink. Complete all spaces or print N/A in spaces that do not apply. Attach additional sheets as needed in same format. NAME OF BUSINESS AND PERSON TO WHICH MONEY IS BEING LOANED, GIFTED OR INVESTED:: YOUR NAME/ENTITY NAME: Last First Middle SOCIAL SECURITY NUMBER: DATE OF BIRTH: MAILING ADDRESS: Street/Route/PO Box City DAY PHONE ( ) County EVENING PHONE ( ) State or Country Zip Code FAX NUMBER ( ) EMPLOYMENT HISTORY OR DATES ENTITY HAS BEEN IN BUSINESS EMPLOYMENT HISTORY (List employment, self-employment, military service, school attendance or unemployment for the last 5 years). Dates From - To: Title: Employer/School ADDRESS: Street or Route Dates From - To: City Title: Employer/School ADDRESS: Street or Route Dates From - To: State or Country City State or Country Title: Employer/School ADDRESS: Street or Route City State or Country ASSETS A BANK and INVESTMENT ACCOUNTS BANK NAME ACCOUNT TYPE (List all bank and investment accounts you have signature authority over, and any accounts of which you are the beneficiary). ACCOUNT NUMBER BALANCE AUTHORIZED SIGNATURE(S) 1. 2. 3. 4. B INCOME SELF/ENTITY MONTHLY SALARY AVERAGE MONTHLY BONUSES/COMMISSIONS/DIVIDENDS OTHER MONTHLY INCOME $ $ $ Original - Agency LIQ 214-50-4/02 (s/Regsvcs/forms/LIQ21450 ) SPOUSE (if applicable) $ $ $ Copy - Applicant Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Liquor License No. C TOTAL CASH OTHER THAN IN BANK: $ LOCATION OF CASH: D NOTES AND ACCOUNTS RECEIVABLE (Moneys owed to you and/or your business - - including this loan) FROM WHOM (Full name, address) MONTHLY PYMT CURRENT BALANCE DUE DATE E REAL ESTATE OWNED ADDRESS OF PROPERTY COVERED F COUNTY TOWNSHIP/RANGE/ SECTION TITLE IN NAME OF VALUE OF LAND AND/OR BUILDING MONTHLY RENT PAID TO YOU VEHICLES/BOATS OWNED YEAR MAKE MODEL VEHICLE/VESSEL ID NUMBER FAIR MARKET VALUE LIABILITIES A NOTES, ACCOUNTS, BILLS, AND CREDIT CARDS OWING (Over $500) TO WHOM (Full Name, Address) CURRENT BALANCE MONTHLY PYMT B MORTGAGES AND CONTRACT OWING (Including rent/lease payments) ADDRESS OF PROPERTY COVERED FULL NAME OF LENDER / LANDLORD CURRENT BALANCE MONTHLY PYMT Do you have (circle one) any interest in/or do you expect to take a percentage of the business profits in exchange for your loan/investment/gift? No Yes If yes, what percent? % SOURCE OF FUNDS: THE AMOUNT LOANED, GIFTED, OR INVESTED: $ DOLLAR AMOUNT INSTRUCTIONS CASH PAID $ CASH BORROWED $ EXPLANATION (Attach documentation of the following source of funds) Explain the original source of the cash used. Explain where the cash is or was kept. Explain where the cash was borrowed from. Provide the name and address of the lender. I certify that this Financial/Source of Funds Statement is true and accurate as of this date. I hereby authorize investigation of my financial records and other sources as necessary. Signature Print Name Original - Agency LIQ 214-50-4/02 (s/Regsvcs/forms/LIQ21450 ) Date Copy - Applicant Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com