State of Washington Business Licensing Service PO Box 9034 Olympia WA 98507-9034 1-800-451-7985 UBI number License number Complete all spaces or print N/A in spaces that do not apply. Note: One financial statement form must be completed for each organization and individual required to have a background check performed as part of this endorsement application. Financial Statement General information Business name DBA or trade name Financial information as of Specify date Type of endorsement you are applying for: Liquor This Financial Statement is for: Choose either No. 1 or No. 2, and complete appropriate section o 1. An individual (can be joint for husband and wife) I am a: (Check appropriate boxes) o Sole proprietor o Corp. officer Title:_______________________ Name Last Home mailing address Street or route Day/cell phone ( ) First City Evening phone ( ) County o o Spouse o Limited partner Stockholder (10% or more) o o Financier o LLC member Other:_________________________ Middle State or country Fax number ( ) Zip code o 2. A business entity Business entity is a: Name of business entity Home mailing address Street or route Day/cell phone ( ) City Evening phone ( ) County State or country Fax number ( ) Zip code o Corporation o Limited partnership o Limited liability company o Limited liability partnership A Assets (at lower cost or market value) Bank checking accounts (list in E) Bank savings accounts (list in F) Life insurance Cash on hand Stocks, bonds, mutual funds, IRAs, etc. (list in G) Notes/accounts receivable (list in H) Business/other investments (list in I) Real estate owned (list in J) Mortgages, leases, contracts owned (list in K) Automobiles, boats, other vehicles (list in L) Miscellaneous property (jewelry, collections, gae/kye) (list in M) Total assets Annual income (all household) Salary (include spouse & other household salaries) Bonus and commissions Dividends Other income (rental, investment interest) Total income Amount B Liabilities (over $500) Notes payable (list in N) Taxes payable (list in N) Accounts and bills payable (list in O) Credit cards/consumer debts/student loans (auto, etc., list in P) Leases and contracts owing (list in Q) Mortgages and liens on real estate (list in Q) Court ordered payments (list in R) Total liabilities Net worth = Total assets minus total liabilities Amount C Amount D Total liabilities and net worth Personal information Other business interests (list all over 5% ownership): For assistance or to request this document in an alternate format, visit http://business.wa.gov/BLS or call 1-800-451-7985. Teletype (TTY) users may call 360-705-6718. BLS-700-303 (2/24/16) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Assets E Checking accounts Bank name Account type Account number Balance Authorized signers F Savings accounts Bank name Account type Account number Balance Authorized signers G Stocks, bonds, mutual funds, IRAs, 401Ks Company Investment type (mutual fund, stock, etc.) & acct # Date acquired No. of shares/ face value Market value Authorized signers H Notes and accounts receivable (monies owed to you or your business) Current balance From whom (full name, address & phone number) Monthly pmt Date acquired Due date I Business and other investments Business investment name Fair market value Annual revenues Date acquired J Real estate owned Address of property Date acquired Purchase price Name on title Land/building value Mortgage balance K Mortgages, leases and contracts owned (paid to you/receivable) Description or address Full name of Debtor Phone Pmt sched Amount past due Original balance Interest rate L Automobiles, boats and other vehicles (industrial, recreational, farm) Make, model, description Year Date acquired Name on title Purchase price Fair market value M Miscellaneous property (jewelry, collections, gae/kye) Description Date acquired Purchase price Current balance Fair market value BLS-700-303 (5/17/11) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Liabilities N Notes and taxes payable (owed by you) To whom (Full name, address, and phone number) Original date obligated Current balance Monthly payment Due date O Accounts and bills payable (owed by you) To whom (Full name, address, and phone number) Original date obligated Current balance Monthly payment Due date P Consumer debts/student loans (credit cards, auto, other) Type of debt Name of lender Original balance Interest rate Monthly pmt Current balance Q Leases, mortgages and contracts owing (paid by you/payable) Include rent payments Property address Full name of lender/landlord Phone Current balance Amount past due Monthly payment Original balance Interest rate R Court ordered payments To whom Original ordered amount Date of order Monthly payment Current balance Additional financial information Attach additional pages to fully explain any "YES" answers to the questions below. Attach copies of documents and court papers. 1. Is anyone a guarantor, endorser or co-signer on any of your personal or business debts, contracts, leases or other liabilities? ....... 2. Are there any outstanding judgements against you or any business in which you had 5% or more ownership or financial interest? 3. Have you or any business in which you had 5% or more ownership or financial interest been directly or indirectly obligated on any loan which resulted in foreclosure, transfer of title in lieu of foreclosure, or judgements? ................................................................... 4. Are you or any business in which you had 5% or more ownership or financial interest delinquent or past due on any federal debt or any other loans or financial obligations? ............................................................................................................................................. 5. Have you or any business in which you had 5% or more ownership or financial interest ever been required to make court-ordered payments? ........................................................................................................................................................................................... 6. Have you or any business in which you had 5% or more ownership or financial interest been a defendent in any suits or legal actions regarding financial matters within the last five years?................................................................................................................. 7. Have you ever filed for person