Licensing & Regulation PO Box 43098 Olympia, WA 98504-3098 Phone: 360-664-1600 FAX: 360-753-2710 www.liq.wa.gov. License Number Trade Name UBI Number Outline of Costs Explanation of All Funds Used For Your Current Application: Real Property (land and building): Lease rental (one month + deposit, if any) OR total purchase cost ............................................... Business Purchase Cost: Purchase & Sale Agreement normally includes trade name, good will, equipment, inventory, corporate stock or LLC units................................................................................................. Cost Of Opening A New Business (equipment, furniture, inventory) or Cost To Change Your Currently Licensed Premises.............................................. Remodeling/Leasehold Improvements/Construction............................................. Miscellaneous Fees (examples are: license/gambling, legal, architectural, health/city/county permits, opening and closing costs, working capital, etc)............................................................ [The Outline of Costs Total must equal the Source of Funds total in- No 7 below] $ $ $ $ $ $ Outline of Costs Total Source of Funds and Certification for All Liquor License Application Funds 1. Savings/Checking/Investment Accounts: Bank/Institution Name: Bank/Institution Name: Bank/Institution Name: Account #: Account #: Account #: $ $ $ Total $ 2. Loans From Banks/Mortgage Companies/Credit Cards, Etc: Bank/Institution Name: Bank/Institution Name: Bank/Institution Name: Account #: Account #: Account #: $ $ $ Total $ 3. Cash Borrowed, Gifted, Or Loaned From A Personal Source: Bank/Institution Name: Bank/Institution Name: Bank/Institution Name: Account #: Account #: Account #: $ $ $ Total $ 4. Sale of Property: (Explain the type of property and the sale date. Include the property address for the sale of land.) Total $ 5. Explain The Source Of Money Kept At Home: Total $ 6. Deferred Contracts (Promissory Notes): Contract with: Contract with: Dollar Amount Dollar Amount $ $ Total $ 7. Other (To include landlord improvements; non-monetary contributions such as labor & equipment) Total $ [The Source of Funds total must equal the Outline of Costs total in No. 1 above] .... Source of Funds Total $ 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 825 8/13 American LegalNet, Inc. www.FormsWorkFlow.com