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AFFIDA~Tr CERTIFYING ANNU,4J~ NON ENTOXICATING MALT LIQUOR <br /> ~ALES OF LESS THAN $10,000 ON-SALE ($20,000 OFF-SAI.E) <br /> <br />iN-me ~f Establishment) <br /> <br />(Address of Estabhshmeht) <br /> <br />I hereby state that the 3.2% beer sales were less than $10,000 for the preceding <br />year ($20,000 Off-Sale). <br /> <br />That the named licensee's fiscal year last ended prior to this statement <br />began, . ., ,199.__ and ended , ~ 199_. <br /> <br />That during that fiscal year, non intoxicating matt liquor sales (3.2% beer <br />sales); whether collected for or not, totaled $ <br /> <br />That during that same fiscal year, purchases of non intoxicating malt <br />liquor'(whether paid for or not during that fiscal year) totaled $ <br /> <br />(tndividuaJ Owner) (Partnership) <br /> <br />by ~ignatur'e <br />Title <br /> <br />(Corporation) <br /> <br />Subscribed and sworn to before me this . . <br /> <br />Notary Public <br /> <br />.IZl <br /> <br /> <br />