Licensing and Regulation Division PO Box 43098 Olympia WA 98504-3098 360-664-1600 Fax 360-753-2710 www.liq.wa.gov License No _____________________________________ Trade Name ____________________________________ UBI No ________________________________________ Tied House Statement – Non-retail Trade Name__________________________ License No. _________________ I understand under the provisions of RCW 66.28.010: • I have no financial interest, directly or indirectly, in any retailer of alcoholic beverages in Washington State. • I have no ownership, stock* or investment in any retailer of alcoholic beverages in Washington State. • No person, officer, investor, or entity with an ownership interest in the business I am licensing has any financial interest, directly or indirectly, in any retailer of alcoholic beverages in Washington State, nor have they any stock* or investment in any retailer of alcoholic beverages in Washington State. I have not, nor has any officer, investor, or entity with an ownership interest in the business I am licensing provided, directly or indirectly, any money, financial assistance, advertising, and sponsorship or promotion fees to any retailer of alcoholic beverages in Washington State. • • I have not, nor has any officer, investor, or entity with an ownership interest in the business I am licensing entered into any oral or written advertising, sponsorship, promotion, or trademark agreement, arrangement, or contract with any retailer of alcoholic beverages prohibited by RCW 66.28.010. • No subsidiary, affiliated, or parent company of the business I am licensing has any financial interest in or provides any money directly or indirectly to any retailer of alcoholic beverages. No subsidiary, affiliated, or parent company of the business I am licensing has entered into any oral or written, advertising, sponsorship, promotion or trademark agreement, arrangement or contract with any retailer of alcoholic beverages prohibited by RCW 66.28.010. • I have not nor has any officer, investor, or entity with an ownership interest in the business I am licensing leased property to any retailer of alcoholic beverages, except property leased to licensed spirits, beer, wine restaurants located on the same or contiguous property of my Washington licensed brewery, winery or distillery. • I understand the restrictions of RCW 66.28.010 remain in effect as long as I am a party of interest in a manufacturer, importer, or distributor of alcoholic beverages. *Unless the stock is held in a mutual or retirement fund in which I have no controlling or voting interest. By signing this form I acknowledge my understanding of the above and that any violation of this statement is cause for denial of a license or revocation of any liquor licenses currently held. Print Name Title Signature of sole proprietor, partner, officer, stockholder, LLC member Date LIQ 715-50-12/05 American LegalNet, Inc. www.FormsWorkflow.com