A
LCOHOLIC BEVERAGE CONTROL
109 SW 9
th
STREET
P.O. B
OX 3506
T
OPEKA KS 66601-3506
☐ ☐
STATE OF KANSAS
DEPARTMENT OF REVENUE
P
HONE: 785-296-7015
F
AX: 785-296-7185
www.ksrevenue.org/abc.html
FINANCIAL DISCLOSURE
FEIN
SECTION 1 – LICENSEE INFORMATION
Licensee DBA Name Owner Name
Completed By Date
SECTION 2 – FINANCIAL DISCLOSURE – NEW APPLICANTS ONLY
SOURCE OF FUNDS:
The total amount you have invested or will invest to open this business including cash (currency and financial asset
accounts), notes, loans and operating capital:
$
Amount:
DOLLAR AMOUNT BY SOURCE:
Identify the sources of all funds (including asset financial accounts and loans) you have invested or will invest in this business as listed above.
List all bank account numbers and the amount derived from each source. Also identify all persons authorized to sign on, or who are part
owners of said account(s). Attach copies of promissory notes or loan agreements along with amortization schedule used for this
business. For cash accounts, attach a copy of the latest bank account statement.
Sources & Account Numbers Names of Authorized Persons on Account SSN or FEIN Amount
$
$
$
$
$
$
$
$
$
$
CASH OTHER THAN IN FINANCIAL ACCOUNTS:
$
U.S. Currency you accumulated over time that you will invest in the business.
OWNERSHIP OF FURNITURE AND EQUIPMENT:
Do you own the furniture, fixtures and equipment at the proposed license location?
Yes No
If “No”, state from whom leased. Name:
ACCOUNTANT/BOOKKEEPER:
List the name, address and telephone number of the accountant or bookkeeper for your business (if applicable).
NAME
STREET ADDRESS
CITY / STATE / ZIP CODE
TELEPHONE
E-MAIL ADDRESS
Page 1 of 1
ABC-801 (Rev. 02/18)
