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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 Establis~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 7- /' <br />__., 199 ~ and ended ~- 2 6~ ,199_~._. <br /> <br />That during that fiscal year, non intoxicating malt liquor sales (3.2% beer sales), whether <br />collected for or not, totaled $ ~ ~'t> ~9 <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 $ 3,, ~ a P. <br /> <br />(In~ers ~l~)~(C~o ~ oratio n) <br /> <br />Title <br /> <br />Subscribed and sworn to before me this <br /> <br />~'~ tIOTARYPUBLIC4,1JNNE$O'I~ ~ <br />.~ ~ I~/Commlssion Ex~ires J~,$1,2000~ <br /> <br /> <br />