Licensing and Regulation Division License No _________________________________
PO Box 43098
Olympia WA 98504-3098
360/664-1600 Trade Name ________________________________
FAX 360/753-2710
www.liq.wa.gov
UBI No _____________________________________
OUTLINE OF COSTS
Please complete the Outline of Costs stating ALL FUNDS used for your current
application.
(If you are making a change to your current business that already has a liquor license, state only the
funds needed for this change to your business.)
REAL PROPERTY (land and building):
Lease rental (one month + deposit, if any) OR
Total purchase cost $________________
Business purchase cost (Purchase & Sale Agreement normally $________________
includes trade name, good will, equipment, inventory,
corporate stock or LLC units
Costs of opening a new business (equipment, furniture, inventory) $________________
OR COST TO CHANGE YOUR CURRENTLY LICENSED BUSINESS
Remodeling/leasehold improvements/construction $________________
Miscellaneous fees (such as license/gambling, legal, architectural, $________________
health/city/county permits, opening and closing costs, working
capital, etc.)
GRAND TOTAL of costs $________________*
* This total should equal the sum of ALL Source
of Funds forms completed for this application
CERTIFICATION I certify under penalty of perjury that all answers and statements are true, correct and complete. I
understand that untruthful or misleading answers are cause for rejection of my application and/or
revocation of any license granted. I hereby authorize investigation of my criminal history, financial
records and other sources as necessary for licensing.
PRINT NAME _______________________________________________________
SIGNATURE __________________________________________________________________ DATE __________________
(Sole proprietor, partner, corporate officer or limited liability company manager or member)
LIQ 823 - 8/09
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