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Affidavit of Kansas Farm Winery Regarding Compliance with Requirement to Use
30% Kansas Products Pursuant to Subsection (c) of K.S.A. 41-308a
Applicant for Initial License
STATE OF KANSAS
SS:
COUNTY OF ________________________
The undersigned, a duly authorized representative of the Kansas Farm Winery indicated below,
being of lawful age and being first duly sworn, on his/her oath states that said Kansas Farm Winery is
applying for an initial license and that at least thirty percent (30%) of the agricultural products which it will
be using in all of the wine it will producing during the first year of licensure will be grown in Kansas, as
required by subsection (c) of K.S.A. 41-308a.
Further affiant sayeth not.
_______________________________________
Signature of affiant
_______________________________________
Typed or printed name of affiant
_______________________________________
DBA Name of Kansas Farm Winery
SUBSCRIBED AND SWORN TO before me this day of
, 20_______.
__________________________
_____________________________
_______________________________________
Notary Public
ABC-255 (Rev. 7.1.12)
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