Lease Information Affidavit
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Lease Information Affidavit Form. This is a Washington form and can be use in Liquor Control Board Statewide.
Tags: Lease Information Affidavit, LIQ 781-50, Washington Statewide, Liquor Control Board
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
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