Washington State Liquor and Cannabis Board PO Box 43075 Olympia WA 98504-3075 www.lcb.wa.gov MOTEL GUEST STATEMENT OF DECLARATION AS REQUIRED BY RCW 66.24.540 AND WAC 314-02-080 I understand that I am subject to a fine and/or imprisonment for any false statement made on this form. I have presented legal proof of age indicating that I am twenty-one years of age or older. No one under twenty-one years of age will have access to the liquor in the honor bar. Print Name Date and Time Signature Address I certify and declare under penalty of perjury of the laws of the state of Washington that the above declarations are true and correct. I am aware that the penalty for furnishing liquor to persons under 21 years of age is a fine of up to $500 and/or 60 days in jail. I am aware that any misrepresentation of fact may result in a criminal charge punishable by time in jail and/or a fine. LIQ 143-e 7/15 American LegalNet, Inc. www.FormsWorkFlow.com