Form Bls-700-303 - Financial Statement
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1
2
3State of Washington
UBI number
Business Licensing Service
PO Box 9034
License number
Olympia WA 98507-9034
1-800-451-7985
Financial Statement
Complete all spaces or print N/A in spaces that do not apply.
Note: One financial statement form must be completed for each organization and individual required to have a
background check performed as part of this license application.
General information
Business name DBA or trade name
Financial information as of Specify date
Type of licenses you are applying for:
Liquor
Gambling
This Financial Statement is for: Choose either No. 1 or No. 2, and complete appropriate section
o 1. An individual (can be joint for husband and wife)
o
o
o
o
o
I am a: (Check appropriate boxes)
Sole proprietor
Spouse
Limited partner
Financier
LLC member
o
o
o
Corp. officer
Title:_______________________
Stockholder (10% or more)
Other:_________________________
Name Last
First
Middle
Home mailing address Street or route
City
County
State or country
Zip code
Day/cell phone
Evening phone
Fax number
(
)
(
)
(
)
o 2. A business entity
o
o
o
o
Business entity is a:
Corporation
Limited partnership
Limited liability company
Limited liability partnership
Name of business entity
Home mailing address Street or route
City
County
State or country
Zip code
Day/cell phone
Evening phone
Fax number
(
)
(
)
(
)
Assets (at lower cost or market value)
Amount
Liabilities (over $500)
Amount
A
B
Bank checking accounts (list in E)
Notes payable (list in N)
Bank savings accounts (list in F)
Taxes payable (list in N)
Life insurance
Accounts and bills payable (list in O)
Credit cards/consumer debts/student loans
Cash on hand
(auto, etc., list in P)
Stocks, bonds, mutual funds, IRAs, etc. (list in G)
Leases and contracts owing (list in Q)
Notes/accounts receivable (list in H)
Mortgages and liens on real estate (list in Q)
Business/other investments (list in I)
Court ordered payments (list in R)
Real estate owned (list in J)
0.00
Mortgages, leases, contracts owned (list in K)
Total liabilities
Automobiles, boats, other vehicles (list in L)
Net worth = Total assets minus total liabilities
Miscellaneous property (jewelry, collections,
0.00
gae/kye) (list in M)
0.00
Total assets
0.00
Total liabilities and net worth
C
Annual income (all household)
Amount
D
Personal information
Salary (include spouse & other household salaries)
Other business interests (list all over 5% ownership):
Bonus and commissions
Dividends
Other income (rental, investment interest)
0.00
Total income
For assistance or to request this document in an alternate format, visit or call 1-800-451-7985. Teletype (TTY) users may call 360-705-6718.
BLS-700-303 (5/17/11) Page 1 of 3
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