ABCD (07/2014)
ALCOHOLIC BEVERAGE CONTROL
PERMIT DEPARTMENT
P.O. Box 22828 Jackson, MS 39225
SUMMARY FINANCIAL STATEMENT
I.
Name
(Last
(First) (Middle / Maiden)
II.
Name of business
III.
Financial statement is:
Personal
Partnership
Corporation
Trust
LLC
IV.
List checking, savings, and/or loan institution references. Continue on separate page if needed:
Checking:
(Institution Name) (Account Number)
Savings:
(Institution Name) (Account Number)
Loan:
(Institution Name) (Account Number)
V.
List each asset, tangible or intangible, below. These amounts are accurate as of _, _ .
Current Assets
Cash on hand $_
Cash on deposit $_
Accounts
& Notes Receivable $_
Investments
Stocks and Bonds $_
Business Investment $_
Fixed Assets
Real Estate $
Other
$
Total Assets $_
VI.
List each liability below. These amounts are accurate as of
_,
.
Current Liabilities (debts due within one year)
Accounts Payable (ex. credit cards) $
Taxes Payable
$
Other
$
Long Term Liabilities (debts due in more than one year)
Notes Payable. $
Mortgages Payable $
Other
$
Total Liabilities $
WAIVER AND AUTHORIZATION TO RELEASE FINANCIAL INFORMATION
TO WHOM IT MAY CONCERN:
I hereby request and authorize you to furnish the Alcoholic Beverage Control Division, Department of Revenue, with any and all
information you may have concerning me or my financial records and copy such records, whether or not such documents would
otherwise be protected from disclosure by any constitutional, statutory, or common law privilege. I agree to indemnify and hold
harmless the person to whom this request is presented from all manner of actions arising out of or by reason of complying with this
request.
By checking this box, you are affixing an electronic signature and thereby swearing under oath that all information
contained in the document is true and correct. Should you knowingly submit information in the document that is false or affix your
electronic signature on behalf of another person or entity without the authority to do so, you will be guilty of perjury, and, upon
conviction, may be punished by imprisonment in the State Penitentiary for a term not exceeding ten (10) years.
