Financial Statement Form - Commercial Driver'S License Application And Renewal Form Page 2
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2SCHEDULE A - SECURITIES OWNED - Line 4 of Financial Statement
ISSUER OF STOCKS
NO. OF SHARES
OR BONDS
REGISTERED IN NAME OF
BOOK VALUE MARKET VALUE
OR FACE AMOUNT
None of the above items are pledged as security except items
TOTAL
_________________________________________ in the amount of $
$
SCHEDULE B - FIXED ASSETS AND RESERVES - Lines 26-31 and 58-71 of Financial Statement
INDEBTEDNESS
PROPERTY
COST OR
TITLE IN NAME OF
ASSESSED
MARKET VALUE
AMOUNT
TO WHOM
LOCATION
(Specify if Joint)
VALUE
A Real Estate
Dealer Business
$
B Real Estate
Other
C Leasehold
Improvements
D Machinery, Tools
and Equipment
E Office Furniture
and Fixtures
F Leased Vehicles
G Other
SCHEDULE C - NOTES PAYABLE TO BANKS AND OTHERS - Lines 44 and 45 of Financial Statement
PAYABLE TO
DATE DUE
SECURITY, IF ANY
AMOUNT
A
B
C
D
TOTAL
$
SCHEDULE D - FLOOR-PLAN LIABILITY PAYABLE - Lines 52 - 56 of Financial Statement
NUMBER
FINANCE COMPANY NAME AND ADDRESS
AMOUNT
OF UNITS
A
B
C
Note: If floor-plan liability or the number of units floor-planned under items 52-56 inclusive, exceeds the inventory
TOTAL
value or the number of units listed under items 11-15 inclusive, please furnish us with an explanation.
$
I, the undersigned, certify under penalty of s.946.32 or 345.17 Wis. Stats., that this financial statement and supporting
schedules submitted on behalf of the named applicant are true to the best of my knowledge.
X
(Authorized Dealership Agent, Title)
(Date)
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