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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 Establishment) <br /> <br />5195 142nd Avenue N.W., Ramse¥, MN <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 />That the named licensee's fiscal year last ended prior to this statement began <br />~., 199 and ended ., 199__. <br /> <br />That during that fiscal year, non intoxicating malt liquor sales (3.2% beer sales), whether <br />collected for or not, totaled $. <br /> <br />3. That during that same fiscal year, purchases of non intoxicating malt liquor (whether paid <br /> for or not during that fiscal year) totaled $ <br /> **This application is for a new license. <br /> of Insurance for proof of coverage and the designated amounts· <br /> American (3~I Company d/b/~ Amrmn~-~2367 <br /> (Individual Owner) (Partnership) (Corporation) <br /> <br /> by Signature Matthew/D. Dzarnowski <br /> <br /> Vice <br />Title <br /> <br />American Oil Company d/b/a Amoco 4)2367 I <br /> 55303 I <br /> ~e pre~ I <br /> ~temen I <br /> (3.2~ I <br /> r g malt I <br /> Please refer to the attached Certificate I <br /> he des gnated amoun s. <br /> <br /> dlhl~ <br /> ~er;hip) (Corporation) I <br /> <br /> . D~ar ~wski I <br /> .rican i~, Company <br /> ZOf_ F' brtjarv 1~)98. I <br /> <br />Subscribed and sworn to before me this <br /> <br />presideng, Ame.rican 0~ Company <br /> /~ day Of_ Febrgary <br /> <br /> <br />