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AFFIDAVIT CERTIFYING ANNUAL NON INTOXICATING MALT LIQUOR SALES <br /> OF LESS THAN $10,000 ON-SALE ($20,000 OFF-SALE) <br /> <br />As the licensee for <br /> <br />(Name of Esta~isl~-ent) <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 ($20,000 <br />Off-Sale). <br /> <br />That the named licensee's fiscal year last ended prior to this statement began <br />__., 199._.~ and ended ~ "~O , 199_.~.. <br /> <br />Tho: during that. fiscal year, non intoxicating malt liquor sales [3.2% beer sales), whether <br />collected for or not, totaled $ -7 ~' fd O. O d> <br /> <br />That during that same fiscal year, purchases of non intoxicating malt liquor (whether paid <br />for or not during that fiscal year) totaled $ ~/.r;'O. r;,~ <br /> <br />(Individual Owne~ (Partnership) (Corporation) <br /> <br />bf Signature/ - -' <br /> <br />Subscribed and sworn to before me this I c~'.._~ <br />Notary Public <br /> <br />day of A. ?r',. \ 1999. <br /> <br /> k~ f~_ NOTABY PUBUO:.M. IN_N. ESOT^ <br /> <br /> <br />