Liquor Control Board Licensing and Regulation PO Box 43098 Olympia WA 98504-3098 Phone: (360) 664-1600 Fax: (360) 753-2710 Tied House Statement – Non-retail Affidavit of No Monetary Contribution to Business Trade Name__________________________ License No.______________________ • I am affiliated with the above business making application for a liquor license. I have made no monetary contribution toward this transaction. • I understand under the provisions of RCW 66.28.010, I shall have no financial interest, directly or indirectly, in any retailer of alcoholic beverages in Washington State. • I understand the restriction of RCW 66.28.010 remains in effect as long as I am a party of interest in an importer, manufacturer, bonded warehouse, supplier, ships chandler or distributor, etc. of alcoholic beverages. By signing this form I acknowledge my understanding of the above and any violation of this statement is cause for denial of a license or revocation of any liquor licenses currently held. ________________________________________ Print Name ________________________________________ Signature of partner, officer, stockholder, LLC member or manager LIQ 720-50-10/02 __________________ Date American LegalNet, Inc. www.FormsWorkflow.com