FINANCIAL INFORMATION FORM
BCC-LIC-013 (Rev. 12/17) California Department of Consumer Affairs
Bureau of Cannabis Control bcc.
State of California Gavin Newsom, Governor
FINANCIAL INFORMATION FORM
Instructions: You must complete every section on the form for each item that is listed. Forms that are incomplete will be returned.
FINANCIAL HISTORY - Attach additional copies if needed
Section A - List all investments made into the applicant's commercial cannabis business
1. Name of Investor
Address
Phone Number
Term(s) of Investment 2. Name of Investor
Address
Date of Investment
Amount
$
Phone Number
Term(s) of Investment 3. Name of Investor
Address
Date of Investment
Amount
$
Phone Number
Term(s) of Investment 4. Name of Investor
Address
Date of Investment
Amount
$
Phone Number
Term(s) of Investment
SECTION B - List all loans made to the applicant's commercial cannabis business
1. Name of Lender
Address
Date of Investment
Amount $
Phone Number
Term(s) of Loan 2. Name of Lender
Address
Security Provided For Loan
Date of Loan
Amount $ Phone Number
Term(s) of Loan 3. Name of Lender
Address
Security Provided For Loan
Date of Loan
Amount $ Phone Number
Term(s) of Loan
Security Provided For Loan
Date of Loan
Amount
$
SECTION C - List all funds belonging to the applicant Financial Institution Name Address
Account Type
Account Number
Amount
$
Financial Institution Name Address
Account Type
Account Number
Amount
$
Financial Institution Name Address
Account Type
Account Number
Amount
$
Financial Institution Name Address
Account Type
Account Number
Amount
$
SECTION D - List all gifts of any kind given to the applicant for use in conducting commercial cannabis activity
Name of Provider
Address
Phone Number
Value/Description of Gift
Name of Provider
Address
Phone Number
Value/Description of Gift
Name of Provider
Address
Phone Number
Value/Description of Gift
BCC-LIC-013 (Rev. 12/17)
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