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 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 Name: Name: Relationship: Relationship: $ $ 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 and non-monetary contributions such as labor & equipment.] Total $ Total Of All Source Of Funds Must Equal The Outline Of Costs Total 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 8247/15 American LegalNet, Inc. www.FormsWorkFlow.com