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percent of t
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SUBSCRIBED AND SWORN TO before me this day
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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 Renewal 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
renewing an existing license and that
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
renewing an existing license and that percent of the agricultural products which it used in all of
the wine it produced during the past twelve months ending on were
grown in Kansas.
If the percentage indicated above is less than 30%, then said Kansas Farm Winery must attach
to this affidavit a detailed plan as to how it intends to come into compliance with subsection (c) of K.S.A.
41-308a and requests approval of said plan from the Director.
Further affiant sayeth not.
Signature of affiant
Typed or printed name of affiant
DBA Name of Kansas Farm Winery
Kansas license number
SUBSCRIBED AND SWORN TO before me this day of
, 20 .
Notary Public
ABC-257 (Rev. 7.1.12)
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