Individual Financial Affidavit
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1Department of Alcoholic Beverage Control
State of California
INDIVIDUAL FINANCIAL AFFIDAVIT
Edmund G. Brown Jr., Governor
Refer to Form ABC-208-A instructions for who must complete this form.
1. NAME (Last, first, middle)
2. PREMISES ADDRESS (Street number and name, city, zip code)
3. MY TOTAL CONTRIBUTION IS
4. MY CASH CONTRIBUTION IS
$
$
5. SOURCE OF FUNDS (Explain fully)
Source 1
Source 2 (If more than one source)
A. Savings/Checking/Stock Accounts
Financial Institution Name
Financial Institution Address
Account Type
Account Number
Persons Authorized to Sign (Print)
Amount Being Invested
$
$
Source of This Money
B. Loans (e.g., loans from financial institutions, individuals, etc.)
Date of Loan
Amount of Loan
$
$
Term(s)
Security
Lender(s)
Occupation of Lender(s)
C. Sale of Property (e.g., Real estate or personal such as vehicles, jewelry, etc.)
Type of Property
Address of Property
Date Sold
Buyer's Name
Net Proceeds
$
$
D. Other Source of Funds (Inheritance, lawsuit settlements, gifts, etc.)
Source(s)
I understand that falsification of the information on this form may constitute grounds for denial or revocation
of the license(s). For a period of 90 days from this date, I hereby authorize the Department of Alcoholic
Beverage Control, or any of its officers, to examine and secure copies of financial records consisting of
signature cards, checking and savings accounts, notes and loan documents, deposit and withdrawal records,
and escrow documents of my financial institution(s) or any financial records established in connection with
this business. This authorization to examine records at any financial institution may be revoked at any time.
I also authorize the Department of Alcoholic Beverage Control, or any of its officers, to examine and secure
copies of any business records or documents established in connection with this business including, but not
limited to those on file with my bookkeeper. I have read all of the above and declare under penalty of
perjury that each and every statement is true and correct.
6. AFFIANT SIGNATURE
7. DATE SIGNED
8. PLACE SIGNED
9. ATTEST (ABC employee or Notary Public)
ABC-208-B (rev. 01-11)
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