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APPLICATION FOR A NEW LICENSE <br /> 8. FINANCIAL DISCLOSURE <br /> A.Purchase Price for Real Estate N/A <br /> B.Purchase Price for Business Assets <br /> C.Other(Please specify) <br /> D.Total Cost <br /> SOURCE OF CASH CONTRIBUTION <br /> Please provide documentation of available funds.(E.g.Bank or other Financial institution Statements,Bank Letter,etc.) <br /> Name of Contributor Amount of Contribution <br /> 77777777771 <br /> T6ta1 = _ = <br /> SOURCE OF FINANCING <br /> Please provide signed financing documentation. <br /> Name of Lender Amount Type of Financing Is the lender a licensee pursuant <br /> to M.G.L.Ch.13B. <br /> ` ()Yes No <br /> ()Yes Q No <br /> ()Yes Q No <br /> ()Yes Q No <br /> FINANCIAL INFORMATION <br /> Provide a detailed explanation of the forms)and source(s)of funding forthe cost identified above. <br /> 9. PLEDGE INFORMATION <br /> Please provide signed pledge documentation. <br /> Are you seeking approval for a pledge?()Yes a No <br /> Please indicate what you are seeking to pledge(check alt that apply) ❑ License ❑ Stock ❑ Inventory <br /> To whom is the pledge being made? <br /> 4 <br />