Licensing & Regulation PO Box 43098 Olympia, WA 98504-3098 Phone: 360-664-1600 FAX: 360-753-2710 www.lcb.wa.gov License Number Trade Name UBI Number Outline of Costs Please complete the Outline of Costs stating all funds used for your current application. Note: If you are making a change to your current business that already has a liquor license, state only the funds needed for this change to your business. Real Property (land and building): Lease rental (one month + deposit, if any) or Total Purchase Cost Business Purchase Cost: Purchase and Sale Agreement normally includes trade name, good will, inventory, corporate stock or LLC units. Costs of Opening a New Business (equipment, furniture, inventory) or Cost to Change Your Currently Licensed Business Additional Costs: Remodeling/Leasehold Improvements/Construction Miscellaneous Fees: Examples: license/gambling, legal, architectural, health/city/county permits, opening and closing costs, working capital, etc. *Grand Total of Costs $0.00 *Grand Total of Costs should equal the sum of all source-of-fund forms completed for this application. Certification: I certify under penalty of perjury that all answers and statements are true, correct and complete. I understand that untruthful or misleading answers are cause for rejection of my application and/or revocation of any license granted. I hereby authorize investigation of my criminal history, financial records and other sources as necessary for licensing. Click here to select your title Print Name Signature Date LIQ 823 7/15 American LegalNet, Inc. www.FormsWorkFlow.com