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AFFIDAVIT CERTIFYING ANNUAL NON INTOXICATING MALT LIQUOR SALES <br /> OF LESS THAN $10,000 ON-SALE ($207000 OFF-SALE) <br /> <br />As the licensee for <br /> <br />(Name of Establishment) <br /> <br />(Address of Establishment) <br /> <br />I hereby state that the 3.2% beer sales were less than $I0,000 for the preceding year ($20,000 <br />Off-Sale). <br /> <br />1. That the <br /> named licensee's fiscal yeay. last ended prior to this statement began <br /> ~ , 199 C~c~ and ended <br /> <br />2. That during that fiscal year, non intoxicating malt liqu~or sales (3.2% beer sales), whether <br /> collected for or not, totaled $ <br /> <br />o <br /> <br />That during that same fiscal year, purchases of_gon intoxicating malt liquor (whether paid <br />for or not during that fiscal year) totaled $ <br /> <br /> (Individual Owner) (Partnership) (Corporation) <br /> <br />,%y sig a e <br /> <br />TitIe <br /> <br />Subscribed and sworn to before me this <br /> <br />Notary Public- - <br /> <br />I <br /> <br />! <br />I <br />I <br /> <br /> <br />