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AFFIDAIFiT CE'RTI]ZYIING AI'qNUAL NON INTOXICATING MALT LIQUOR SALES <br /> OF LESS THAIN $10,000 ON-SALE ($20,000 OFF-SALE) <br /> <br />the licensee for <br /> (Name of Estab[iskrnent) <br /> <br /> (Address of Establishment) <br /> <br />I hereby state that the 3.2% beer sales were less than $10,000 for the preceding year ($213,000 <br /> <br />Off-Sale) <br />1. <br /> <br />., <br /> <br />That the named licensee's fiscal year last ended prior to this statement began <br />2000 and ended ,2001. <br /> <br />That during that fiscal year, non intoxicating malt liquor sales (.3.2% beer sales.), whether <br />collected for or not, totaled $ <br /> <br />That during that same fiscal year, purchases of non-intoxicating malt liquor (whether pad <br />for or not during that fiscal year) totaled $ <br /> <br />(Individual Owner) (Partnership) (Corporation) <br /> <br />by Signature <br /> <br />Title <br /> <br />Subscribed and sworn to before me th/s <br /> <br />day of ,2001 <br /> <br />Notary .Public <br /> <br /> <br />