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r <br />� v <br />AFFIDAVIT ESTABLISHING THAT OCT 2 B 2016 <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 O'Sullivans Holiday . I certify that: <br />(trade name of business) <br />My sales of on -sale 3.2 percent malt liquor were less than $25,000 for the <br />preceding year. <br />❑ My sales of aff-sale 3.2 Percent malt liquor were less than $50,000 for the <br />preceding year. <br />❑ My sales of on -sale wine were less than $25,000 for the preceding year. <br />[] I hold a temporary wine license issued under the law. <br />Signature of licensee: Date: t,* �� � f 6 <br />STATE OF MINNESOTA <br />COUNTY OF HENNEPIN <br />is instnarnent was acknowledged before me this Leu-- day of 20 l 1P <br />by 13,6-4-- t�_ i>03 as SAar Act_iji..+--- <br />_ (person's name) a (#itle) <br />0 <br />name of business) <br />L ROUFS <br />(STAMP) <br />SCHARLENE. NOTARY PUBLIC <br />MINNESOTA <br />rycoMml!!lal� 6tp11�Jaf.91, 2018 <br />Notary Public <br />Page 7 <br />