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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 If money is withdrawn from multiple accounts, list how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
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