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AFFIDAVIT ESTABLISHING THAT <br />NO INSURANCE IS REQUIRED <br />FOR 3.2 PERCENT MALT LIQUOR LICENSEES <br />OR HOLDERS OF ON -SALE WINE LICENSES <br />3.2 percent malt liquor licensees and holders of on -sale or temporary wine licenses may either show <br />proof of insurance, or in place of insurance, provide an affidavit stating that their on -sale for the <br />previous year is less than $25,000 and that the off -sale for the previous year is less than $50,000. <br />Please complete the following information, check the appropriate license(s), sign and have your <br />signature notarized. <br />As licensee of Orono Public Golf Course , I certify that: <br />(trade name of business) <br />a My sales of on -sale 3.2 percent malt liquor were less than $25,000 for the preceding <br />year. <br />❑ My sales of off -sale 3.2 percent malt lir were less than $50,000 for the preceding <br />year. <br />My sales of on -sale wine were less than $25,000 for the preceding year. <br />❑ 1 hold a temporary wine license issued under the law. <br />VSignature of licensee: Date: <br />STATE OF MINNESOTA <br />COUNTY OF HENNEPIN <br />This instrument was acknowledged before me this day of , 20 <br />by as <br />(person's name) (title) <br />M <br />(trade name of business) <br />(STAMP) <br />Notary Public <br />Page 7 <br />