Affidavit Form - City Of Independence, Missouri Finance Department (Page 3 of 4) in pdf

Affidavit Form - City Of Independence, Missouri Finance Department Page 3

IF BUSINESS IS OWNED BY PARTNERSHIP, COMPLETE THE FOLLOWING:

21.

Name, home addresses, and telephone numbers of all partners, and percentage of ownership of business:

IF BUSINESS IS OWNED BY CORPORATION OR LIMITED LIABILITY COMPANY, COMPLETE THE

FOLLOWING:

22.

Name, address, and telephone number of corporation or LLC:

23.

State in which incorporated or organized

Date of incorporation or organization

24.

Amount of paid-in capital

Authorized capital

25.

Names and addresses of president, vice-president, treasurer and secretary of corporation. If LLC, names and addresses

of members

26.

Name and address of Managing Officer

27.

If corporation, names and addresses of all stockholders who hold 10% or more of the capital stock

28.

Is the corporation, any stockholder, or managing officer thereof, any member of his or her household or immediate

family, the LLC, any member, or managing officer thereof, any member of his or her household or immediate family,

interested, directly or indirectly, in any other license issued by the Supervisor of Liquor Control of this State or any

other State which is now in force?

If so, give details

29.

Has the corporation, any stockholder, or managing officer thereof, any member of his or her family, the LLC, any

member, manager, or managing officer thereof, any member of his or her family, at any time in the past, held a license

from the Supervisor of Liquor Control of this State or any other State?

If so, give name of such licensee

and location of premises

30.

Has any stockholder of the corporation, member or manager of the LLC, or the managing officer ever been employed

Affidavit Form - City Of Independence, Missouri Finance Department Page 3