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FINANCIAL DISCLOSURE STATEMENT
<br /> Off-Sale Liquor License (Iixtoxicating)
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<br />III.
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<br />State full names, residences, business addresses and telephone numbers of the owner or owners of
<br />the building wherein the licensed business wkLl be located, if the owner is off, er than the applicant
<br />(ff other than new construction).
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<br />Where the building is owned by a a conditions of the lease
<br />arrangement, such as, term of lease, monthly rental, renewal privileges, etc. ~, . _
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<br />If the building is owne2 b?the inaividual applicant, partnership, corporation, or assocmtion, state:
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<br />A) Date purchased (or planned completion date for new construction).
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<br />B) If new consh~uction, total cost of the building and method of financing such cost.
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<br />2) If contract for deed, name and address of holder of such contract for'deed.
<br />3) Rate of interest on mortgage or contract for deed.
<br />4) Ivlonthly payment for liquidation of mortgage and/or contract for deed.
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<br />State the total cost of assets acquired to start this business including the business premises, Lt'
<br />purchased, fixtures, furniture, equipment, merchandise for resale, cash for working capital, prepaid
<br />insurance, and any other assets.
<br />
<br />^)
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<br />Of the above costs of assets acquired, state the amount that is provided by the person(s)
<br />investing in this business (attach proof of the sOurce of such money).
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<br />Full Name:
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<br />Give full names, addresses, telephone numbers of all persons, other than the applicant, who have
<br />any financial interest Ln the business, buildings, premises, fLxtures, furniture, or stock m trade. State
<br />the nature of the interest amount thereof, and the terms for payment or other reimbursement (this
<br />shall include, but not be limited to, any leasees, lessors, mortgagors, mortgagees, lendees, hen
<br />holders, trustees, n'ustors and persons who have cosigned notes or otherwise loaned, pledged or
<br />extended security for any indebtedness of the applicant).
<br /> ,1~'~C~4- !'~-4~t;~-'hc, ~ ~. c,,'~ ~ G-~ ~,get,-' Phone Number:
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<br />Nature of Interest: ~'r~4','~
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<br />!
<br />!
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<br />Full Name:
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<br />Address:
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<br />Nature of Interest:
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<br />Phone .Number:
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<br />-157-
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