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1191111111,11 NAN CIAL DISCLOSURE <br /> Re uired for the followi <br /> .................... tions:.1 <br /> Change of Officers,Stock or Ownership Interest(E.g. New Stockholder/Transfer or Issuance of Stock) <br /> Change of Premises Information <br /> Pledge of License, Inventory or Stock <br /> ............. <br /> Purchase Price N <br /> s : FF/A-NOT AN ACQUISITION <br /> ( ) <br /> RCE 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 /> N/A-NOT AN ACQUISITION <br /> ..............."I..............."I..........1! <br /> ............ <br /> Totad <br /> ............................ ................. <br /> SOURCE OF FINANCING <br /> Please provide signed financing documentation. <br /> ...........7..........-—--------- ................ <br /> s <br /> Name of Lender Amount Type o Is the lender a licensee pursuant <br /> t 0 M. <br /> f Financing <br /> th <br /> e <br /> t C <br /> MG.L.Ch.138. <br /> N/A <br /> Yes C No <br /> ........... <br /> Yes No <br /> ( 'Yes <br /> 'Yes No <br /> ( Yes No <br /> FINANCIAL INFORMATION <br /> Provide a detailed explanation of the form('s)and source(s)of funding for the cost identified above. <br /> N/A-SEE ABOVE <br /> ................. ........ .................... .................. ..................... <br /> 13 <br />