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

RECEIPT FOR SALE OF MALT LIQUOR

TAVERN OR STORE: _______________________ DATE: ______________________

SELLER: _______________________________________________________________

NAME OF PURCHASER: __________________________________________________

ADDRESS OF PURCHASER: ______________________________________________

DRIVER’S LICENSE # ____________________________________________________

KEG IDENTIFICATION # ____________________ SERIAL # ____________________

NO. OF KEGS SOLD: _______________________ TOTAL GALLONS: ____________

BRAND: ________________________________________________________________

ADDRESS OR LOCATION WHERE KEG WILL BE HOUSED AND CONSUMED:

_______________________________________________________________________

I declare under penalty of perjury that 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 or allow to be removed or obliterated the numbered identification label affixed to the container or keg.

PURCHASER SIGNATURE: ________________________________________________