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<br />FINANCIAL DISCLOSURE STATEMENT
<br />Off-Sale Liquor License (Intoxicating)
<br />
<br />II.
<br />
<br />III.
<br />
<br />State full names, residences, business addresses and telephone numbers of the owner or owners of
<br />the building wherein the licensed business will be located, if the owner is other than the apvlicant
<br />
<br />Where the building is owned by other than applicant, state in summary the conditions of the lease
<br />arrangement, such as, term of lease, monthly rental, renewal privileges, etc. (',eft'
<br />If the building is owned by the individual applicant, partnership, corporation, or association, s~e:
<br />A) Date purchased (or planned completion date for new construction). ,~ --/.dc-- ~,~._
<br />B) If new construction, total cost of the building and method of financing such cost.
<br />
<br />1) If financed by mortgage, name 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.
<br />
<br />Mo
<br />
<br />Full Name:
<br />Address:
<br />
<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 /> and any other assets.
<br />insurance,
<br />
<br />A) 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).
<br />
<br />Give full names, addresses, telephone number- s of all persons, other than the applicant, who have
<br />any financial interest in the business, buildings, premises, fixtures, furniture, or stock in trade. State
<br />the nature of the interest amount thereof, and the terms for payment or other reimbursement (this
<br />shah include, but not be limited to, any leasees, lessors, mortgagors, mortgagees, Iendees, lien
<br />holders, trustees, trustors and persons who have cosigned notes or otherwise loaned, pledged or
<br />extended security for any indebtedness of the applicant).
<br /> "~/~ /7~,"L,'/4/7 Phone Number:
<br />
<br />Nature of Interest:
<br />
<br />Full Name:
<br />
<br />Address:
<br />
<br />Nature of Interest:
<br />
<br />Phone Number:
<br />
<br />-47-
<br />
<br />
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