Disclaimer Statement

STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION DISCLAIMER STATEMENT APPLICANT: ____________________________________________________DATE: _____________________ I/WE ___________________________________________________________ , ____________________________ (Name of Lender/s or Account co-owner) (Date of Birth) HAVE RELEASED THE SUM OF $ _____________________ TO ___________________________________________________________________ (Name and Relationship) IN TERMS OF A: LOAN GIFT WITHDRAWL OF CO-OWNED FUNDS TO BE USED FOR THE PURPOSE OF PURCHASING THE __________________________________________ (Type of Business) KNOWN AS _______________________________ LOCATED AT _____________________________________ (Trade Name) (Number & Street) _____________________________________________________________________________________________ I/WE SHALL HAVE NO FINANCIAL INTEREST IN SAID BUSINESS. I/WE PRESENTLY DO NOT HOLD ANY INTEREST, FINANCIAL OR OTHERWISE, IN ANY LIQUOR BUSINESS EXCEPT THE FOLLOWING: _____________________________________________________________________________________________ (If None, print "None") FUNDS WHERE DERIVED FROM _______________________________________________________________ (Account Type, Account Number, Bank Name) _____________________________________________________________________________________________ IF THE PLACE WHERE THE MONEY WAS MAINTAINED IS IN MORE THAN ONE PERSON'S NAME, ALL INDIVIDUALS MUST COMPLETE A DISCLAIMER STATEMENT AND HAVE THEIR SIGNATURES NOTARIZED. I do hereby affirm that the information contained in this affidavit is true to the best of my knowledge. Signature: X ___________________________________________________________ Date: _____________________ Subscribed and affirmed before me: Signed X (Commissioner of Superior Court, Notary Public, Justice of Peace) ____ Date: _____ __ 165 Capitol Avenue, Hartford, Connecticut 06106-1630 Website: http://www.ct.gov/dcp American LegalNet, Inc. www.FormsWorkFlow.com