Form C-809m Manual Reporting-Affidavit - Rbc Direct Investing Inc

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MANUAL REPORTING – AFFIDAVIT
FORM C-809M (09/2011)
(CASH LAW – MALT BEVERAGES)
STATE OF TEXAS
COUNTY OF ___________________________
BEFORE ME, the undersigned authority, this day personally appeared ___________________________________, who
is a credible person, and who, after being by me duly sworn, did depose and say:
That a __________________ No. _________________ dated the _______ day of _______________, ________, in the
(check or instrument)
(check or instrument No.)
(month)
(year)
amount of $__________ was received by ____________________________________of ________________, Texas.
(Manufacturer or Distributor Permittee)
(city)
That said check was received in payment of MALT BEVERAGES delivered on the ________day of _____________,
(month)
_________, to the ________________________________________________________permit number______________,
)
(
(year
Retailer, Mixed Beverage or Private Club Permittee)
located at _______________________________________________________________________________________.
(Address)
That on the __________ day of ____________________, _______, said instrument was dishonored by the drawee
(month)
(year)
_______________________________________________________________________________ for the following
(Name and Address of Bank)
reason(s)_________________________________________________________________________________________.
That said dishonored ___________________ was returned to ______________________________________________
Manufacturer /
(check or instrument)
Distributor or Local Distributor (LP)
on the __________ day of ____________________, _______, resulting in a violation of the cash law.
(TABC Code 102.31)
(month)
(year)
___________________________________________________
Manufacturer / Distributor or Local Distributor (LP)
Permit Number _______________ Phone No. ________________
(Notary Seal)
___________________________________________________
Manufacturer/Distributor or Local Distributor Representative
___________________________________________________
Title
SWORN TO AND SUBSCRIBED BEFORE ME, the undersigned authority, this the _____ day of ____________,_______.
___________________________________________________
Notary Public in and for the State of Texas
A COPY OF THIS Affidavit must be submitted to TABC by one of the following options: email credit.law@tabc.state.tx.us, Fax
(512) 206-3329 or to the address listed below:
TEXAS ALCOHOLIC BEVERAGE COMMISSON
P. O. Box 1327
Austin, Texas 78711

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