Affidavit Form - City Of Independence, Missouri Finance Department
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4CITY OF INDEPENDENCE, MISSOURI
Finance Department - License Division
111 East Maple, Independence, Missouri 64050
816-325-7079
AFFIDAVIT
Application is hereby being made for a license to
Liquor by Drink
sell
manufacture
alcoholic
Non-Intox. Beer by Drink
beverages at:
Malt Liquor/Wine by Drink
Liquor by Package
RETAIL
WHOLESALE
Malt Liquor/Wine by Pkg.
Non-Intox. Beer by Pkg.
__________________ Sunday Sales
Other (specify)
As Sole Owner________ Partnership________ Corporation________ LLC_________
Business Name
Address
Phone
1.
What type of business is the license for?
2.
Give dimensions of the building and include any other areas in which alcoholic beverages may be stored
3.
Is the proposed location within three hundred feet (300') of any church, school, or hospital building?
4.
From whom was the business purchased?
5.
Date of purchase
Purchase price
6.
Amount of down payment
Balance due
7.
Balance due upon approval or chattel
8.
Effective date of possession
9.
Name and address of mortgage holder
Terms of repayment
10.
Did you assume any debts not listed above in connection with the operation of said business?
If so, give full details
11.
Do you rent or lease the premises for which this business is to be used?
If so, give terms
of rent or lease, and name and address of owner of property
12.
What interest, if any, does your landlord have, directly or indirectly, in the business in which you intend to engage
if the license is granted?
13-2-052
13.
Does your landlord now hold, or has he or she every held, a license of any kind issued by the Supervisor of Liquor
Control of this State or any other State?
If so, give details
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Parent category: Financial