Outline Of Costs Source Of Funds And Certification Form. This is a Washington form and can be use in Liquor Control Board Statewide.
Tags: Outline Of Costs Source Of Funds And Certification, LIQ 825-50, Washington Statewide, Liquor Control Board
Trade Name __________________________________ License # ________________ UBI # ___________________________ OUTLINE OF COSTS Please complete the Outline of Costs explaining ALL FUNDS used for your current application. st $___________ Real property purchase amount OR lease deposit plus 1 month’s rent $___________ Business purchase cost (equipment, inventory, trade name, good will, corporate stock or LLC units) $___________ Costs associated with opening a new business (equipment, furniture, inventory) or COST TO CHANGE YOUR CURRENTLY LICENSED PREMISES. $___________ Remodeling/leasehold improvements/construction $___________ Miscellaneous expenses (such as license/gambling, legal, architectural, health/city/county permits, opening and closing costs, working capital, etc) $__________ GRAND TOTAL of Costs SOURCE OF FUNDS and CERTIFICATION Please explain carefully ALL funds used to get into business or change your current liquor license. YOUR EXPLANATION NEEDS TO INCLUDE ALL COSTS OUTLINED ABOVE AND SHOULD EQUAL THE GRAND TOTAL LISTED ABOVE. $___________CASH Explain EACH source of cash such as checking, savings, or investment accounts, trust funds, sale of property, money on hand, etc. as follows: (1) the amount of money, (2) the name of the bank or stock account and (3) the account number. If money is withdrawn from multiple accounts, list how much money comes from each account. (4) Money kept at home must have full explanation of how it was obtained. (5) For the sale of property write a description of the type of property sold, the address of the real property, and the sale finalization date. ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ $___________CASH BORROWED Explain EACH source of cash/credit from bank loans, finance companies, credit cards, or insurance funds as follows: (1) the amount of money, (2) the name of the bank, finance/mortgage company, or credit card, and (3) the account and/or loan number. If money is withdrawn from multiple sources, list how much comes from each source. ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ $___________ CASH BORROWED or GIFTED FROM A PERSONAL SOURCE. State the amounts of money borrowed/gifted as well as the full name and relationship of each person from which the money came. ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ $___________DEFERRED CONTRACTS (Promissory Notes). Give the name of the person, company, or bank to whom these Promissory Notes are written. __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ $___________OTHER (To include landlord improvements; non-monetary contributions such as labor & equipment) __________________________________________________________________________________________________________________ $___________GRAND CERTIFICATION TOTAL of Funds (This total should equal the Grand Total of Costs listed above) 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. PRINT NAME _____________________________________________ SIGNATURE __________________________________________ PLACE (City)________________________ DATE ________________ LIQ 825-50-10/03 American LegalNet, Inc. www.FormsWorkflow.com