HomeMy WebLinkAboutverified statementVERIFIED STATEMENT
STATE OF IOWA )
)ss:
JOHNSON COUNTY )
The undersigned, first being duly sworn upon oath deposes and states:
I,
1. That I have applied for a Class
at the following location:
1. Business Name:
2. Business Address:
hereby verify:
liquor license, wine or beer permit for the following business
2. The regular business hours of this establishment are: (list hours for each day of the week)
3. The following activities, goods and services will be provided at this establishment:
I understand that this Statement will be used by the City to determine whether my business is an "eating
establishment' or a "drinking establishment" as defined by the Iowa City Zoning Code. I further understand
that the City may require me to produce certain records to confirm the information I have provided herein,
including, but not limited to, business records upon which this statement is based, state and federal tax
records, applications for dram shop insurance, audits performed to determine dram shop insurance
premiums and receipts from vendors for goods purchased.
I CERTIFY UNDER PENALTY OF PERJURY AND PERSUANT TO THE LAWS OF THE STATE OF
IOWA THAT THE PRECEDING IS TRUE AND CORRECT.
Dated this day of
(Name)
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Signed and sworn to (or affirmed) before me on this day of
Notary Public in and for the State of Iowa
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