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FINANCIAL DISCLOSURE STATEMENT
<br />Off-Sale Liquor License (Intoxicating)
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<br />II.
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<br />IlL
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<br />State full names, residences, business addresses and telephone numbers of the owner or owners of
<br />the building whereh~ the licensed business will be located, if the owner is other than the applicant
<br />(if other than new construction).
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<br />Where the building is owned by otl~er than applicant, state in summary the conditions of the lease
<br />arrangement, such as, term of lease, monthly rental, renewal privileges, etc. 4' k']
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<br /> e u il lng is o ned b~the ' di idual applicant, parmersnip, corporation, or assocmtion, stare:
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<br />A) Date purchased (or planned completion date for new construction).
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<br />1) If financed by mortgage, hame and address'of mortgage holder.
<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) Monthly payment for liquidation of mortgage and/or contract for deed.
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<br />IV.
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<br />State the total cost of assets acquired to start this business including the business premises, if
<br />purchased, fixtures, furniture, equipment, merchandise for resale, cash for working capital, prepaid
<br />insurance, and any other assets.
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<br />A) Of the above costs of assets acquired, state the amount that is provided by the person(s)
<br /> investing in ~is business (attach proof of the source of such money).
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<br />Full Name:
<br />Address:
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<br />Give full names, addresses, telephone numbers of all persons, other than the applicant, who have
<br />any financial interest in the business, buildings, premises, fixtures, furnit-ure, o.' 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, lien
<br />holders, trustees, trustors and persons who have cosigned notes or otherwise loaned, pledged or
<br />extended Security for any mdebtedness of the applicant).
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<br />Nature of Interest:
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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 />-149-
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