Affidavit Of Transfer And Statement Of Compliance

COLORADO DEPARTMENT OF REVENUE Liquor Enforcement Division 1375 Sherman St, Denver CO 80261 September, 2005 AFFIDAVIT OF TRANSFER AND STATEMENT OF COMPLIANCE Pursuant to the requirements of 12-47-303(3)(b), Colorado Revised Statutes, Licensee hereby states that all accounts for alcohol beverages sold to the Applicant are: Paid in full. There are no outstanding accounts with any Colorado Wholesalers. Licensee hereby certifies that the following is a complete list of accounts for alcohol beverages that are unpaid: Licensee and Applicant agree that all accounts will be paid for from the proceeds at closing by the: Licensee Applicant Licensee unavailable to certify disposition of accounts for alcohol beverages Inventory list attached. Transfer by operation of law - Regulation 47-304. Applicant will assume full responsibility for payment of the outstanding accounts as listed above. No alcohol beverage inventory transferred or sold. Licensee hereby authorizes the transfer of its Colorado Retail Liquor License to the Applicant, its agent, or a company, corporation, partnership or other business entity to be formed by the Applicant. Dated this day of , 200 . Seller: Buyer: Licensee & License Number Applicant Trade name Trade name Signature Position Signature Position Print Name Print Name American LegalNet, Inc. www.FormsWorkflow.com