COM/FED/RLS-367-3 08/19
II. Personalnancialstatement - List below your personal assets and liabilities. Include real estate, bank deposits, stock, bonds,
personal property, loans, mortgages, etc. If none, so state.
Describe assets Amount
Total assets
$
Describe liabilities
Total liabilities
$
III. Personal investment in business
(a) Amount to be invested by applicant: Cash $ _______________________
Equipment $ _______________________
Goodwill $ _______________________
Other $ _______________________ Total $ __________________________
(b) Is applicant’s investment in business to be nanced solely from assets listed in Part II above?
Yes No
(c) If “No” to “b”, list below the amount of additional monies to be invested in the business, the source of same and the name
and address of any person who has undertaken or will undertake to advance monies to the applicant to assist in nancing
said business and the relationship, if any, of each person to the applicant.
Amount __________________________________________________________________________________________
Source ___________________________________________________________________________________________
Name ____________________________________________________________________________________________
Address __________________________________________________________________________________________
Relationship _______________________________________________________________________________________
The applicant whose signature appears below represents under penalty of perjury that the foregoing statements are true and agrees
that they shall be made a part of the application for a license. It is understood that information reported may be used for background
investigation pursuant to the Annotated Code of Maryland, the Alcoholic Beverages Article.
Date Signature of applicant
Amount
Page 2
OCCUPATION RECORD
AND FINANCIAL
STATEMENT OF
INDIVIDUAL LICENSE
APPLICANT
MARYLAND
FORM
367-3
