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 twenty-one (21) except as provided by RCW 66.44.270, and that I will not remove or obliterate the numbered identification label affixed to the container.

Identity of Seller:
Address of Licensed Premises:

NOTICE

It is unlawful for any person under the age of twenty-one (21) years to acquire in any manner, consume or have in his or her possession any intoxicating liquor; provided, that the foregoing shall not apply in the case of liquor given or permitted to be given to such person under the age of twenty-one (21) years by his parent or guardian for beverage or medicinal purposes in the home or administered to him by his physician or dentist for medicinal purposes. A person who signs this receipt with knowledge that any information in the receipt is false commits perjury. Violations of any of the provisions of the Monroe City Ordinance which requires this statement and these terms is a misdemeanor punishable by a fine of not more than five hundred dollars, or by imprisonment not to exceed six months, or by both such fine and imprisonment.