Licensing and Regulation Division PO Box 43098 Olympia WA 98504-3098 Phone: (360) 664-1600 FAX: (360) 753-2710 www.liq.wa.gov _______________________________________________ Trade Name _______________________________________________ License Number ______________________________________________ UBI Number Lease Information Affidavit (RCW 66.24.010/WAC 314-12-035) This affidavit is provided to the Washington State Liquor Control Board as replacement to a copy of the lease and/or the assignment, assumption and consent of lease for the below premises. Information on this document should directly reflect the information on the current lease/assignment ` Lease Information: Trade Name Lease is for (check one or both): Real property Personal property Address of real property: Name of landlord(s): Name of tenant(s): (LLC, partnership, corporation, etc.) Monthly rent: $ Percentage (%) of profit to landlord Lease expiration date: I/We declare under penalty of perjury that all information provided on this form is true and complete to the best of my knowledge, and that at the time of signing the lease is valid. I understand that untruthful, misleading, or incomplete answers whether through misrepresentation, concealment, inadvertence, or mistake are cause for denial of a license or revocation of any liquor licenses currently held. Print name Signature of landlord(s) Print name Date (If landlord representative is signing, attach a landlord authorization or power of attorney) Signature of tenant Date (sole proprietor, officer, partner, LLC member, etc.) LIQ 781-50-2/05 American LegalNet, Inc. www.FormsWorkflow.com