Licensing and Regulation PO Box 43098 Olympia WA 98504-3098 Phone: (360) 664-1600 Fax: (360) 753-2710 www.lcb.wa.gov Liquor License No. Financial 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: DOB: MAILING ADDRESS: Street/Route/PO Box City Last First DAY PHONE ( ) County State or Country Zip Code Middle EMPLOYMENT HISTORY OR DATES ENTITY HAS BEEN IN BUSINESS EMPLOYMENT HISTORY Dates From - To: ADDRESS: Street or Route Dates From - To: ADDRESS: Street or Route Dates From - To: ADDRESS: Street or Route Title: City Title: City (List employment, self-employment, military service, school attendance or unemployment for the last 5 years). Title: City Employer/School State or Country Employer/School State or Country Employer/School State or Country ASSETS A BANK and INVESTMENT ACCOUNTS BANK NAME 1. 2. 3. 4. 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) B INCOME MONTHLY SALARY AVERAGE MONTHLY OTHER MONTHLY INCOME SELF/ENTITY $ $ $ $ $ $ SPOUSE (if applicable) LIQ 214 7/15 *LCB LIQ214* American LegalNet, Inc. www.FormsWorkFlow.com LIQ 214 3/06 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Liquor License No. C TOTAL CASH OTHER THAN IN BANK: $ LOCATION OF CASH: D REAL ESTATE OWNED ADDRESS OF PROPERTY COVERED COUNTY TOWNSHIP/RANGE / SECTION TITLE IN NAME OF VALUE OF LAND AND/OR BUILDING MONTHLY RENT PAID TO YOU E 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 LIABILITIES A MORTGAGES AND CONTRACT OWING (Including rent/lease payments) ADDRESS OF PROPERTY COVERED FULL NAME OF LENDER / LANDLORD CURRENT BALANCE MONTHLY PYMT I certify that this Financial 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 Date LIQ 214 3/06 Page 3 of 2 American LegalNet, Inc. www.FormsWorkFlow.com