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! <br />! <br /> <br />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~nent) <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 rfp' 26~ ,199_~__. <br /> <br />That during that fiscal year, non intoxicating malt liquor sales (3.2% beer sales), whether <br />collected for or not, totaled $.. ~. ~o ~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 ~9 . <br /> <br />(Individual Odwner) (Partnership~ (Corporation) <br /> <br />by Signature <br /> <br />Title <br /> <br />Subscribed and sworn to before me this <br /> <br />/Ol <br /> <br /> <br />