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I <br /> I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br /> <br />AFFIDAVIT CERTIFYING ANNUAL NON INTOXICATING MALT LIQUOR SALES <br /> OF LESS THAN $I0,000 ON-SALE ($20,000 OFF-SALE) <br /> <br />As the licensee for <br /> <br />(Name of Esta~glishr~ent) <br /> <br />~33~ /_9-7.~.,I ~,.~ /'~ <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 />7- / ,199. q 5"and ended /9 - ,~/9 , 199ff__¢ <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 />That during that same fiscal year, purchases of non intoxicating malt liquor (whether paid <br />for or not during that fiscal year) totaled $~ ?~9 ~>. <br /> <br />(Indix~iduai Ox~ner) (Parmership) (Co~oration) <br />b~y Signaturo~ '' <br /> <br />Title r - <br /> <br />Subscribed and sworn to before me this <br /> <br />day of .... 1997. <br /> <br />Notary Public <br /> <br /> <br />