The form of the declaration and receipt required herein shall be substantially in the following form and shall require the information contained in the following form:

Receipt for Sale of Malt Liquor in Kegs or Containers to Unlicensed Persons

Date of Sale     Invoice No.

Keg Identification Number(s)    

Brand    Keg Capacity

No. of Kegs     Total Gallons

Name of Purchaser     

Address     

Address or location where keg will be located     

Motor Vehicle Operator’s License Number    

Washington State Identification Card    

Other Identification

I declare under penalty of perjury the information provided in this receipt is true and correct and that I am over the legal age to purchase, possess or use malt liquor, that I will not allow the malt liquor purchased and identified by this receipt to be consumed by any person who is under the age of 21 years except as provided by RCW 66.44.270, and that I will not remove or obliterate the numbered identification label affixed to the container. I understand that it is a criminal misdemeanor to Not Maintain a copy of this declaration and receipt next to or adjacent to the keg or other container, in no event a distance of greater than five feet and visible without physical barrier from such keg, during the time that the keg or other container is in my possession or under my control.

    Signature of Purchaser

Identity of Seller    

Address of Licensed Premises