HomeMy WebLinkAboutA029 - Affridavit for 10% exemption a SPEED LETTER°
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DAN SIGNED
nCry 44-902•Triplicate
,V SENDER DETACH AND RETAIN YELLOW COPY,SEND WHITE AND PINK COPIES. RECIPIENT:RETAIN WHITE COPY,RETURN PINK COPY. 44-904•Quadruplicate
AFFIDAVIT
SMOKING ORDINANCE
LESS THAN 10% EXEMPTION
STATE OF IOWA
ss:
STORY COUNTY
The undersigned, , being first duly sworn, does hereby depose and
state that:
1. The undersigned is the authorized agent and representative for
2. That is both a food establishment and licensed premises under
the Iowa Alcoholic Beverage Control Act.
3. That sales of non-alcoholic food at are in a dollar amount that is
less than ten percent of the dollar amount of sales of all kinds at
SUBSCRIBED AND SWORN to before me,a Notary Public in and for the State of Iowa,by the affiant
to me personally known,on the day of ,20
Notary Public in and for Story County,Iowa
F85 -Smoking Ordinance Affidavit-052901