Form Cig-1fs - Financial Statemen-Indiana Department Of Revenue Form Page 2

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REAL ESTATE

Value

Description

Improvements

Mortgages

Equity

Assessed Cash

64654654654

65465465

Whose Name is Title to above real estate held?

Real Estate held in Fee Simple, Leasehold or Under Contract?

LIST OF STOCKS AND BONDS OWNED

Date of Last

Name of Corporation

Location

Par Value

Rate

Nature of

Actual Value

Dividend or

Interest

Business

46546654

64654654

654654654

Other Data

Affiliated Concerns

I, the undersigned officer of this corporation, acquainted with its affairs and duly authorized to contract liabilities, hereby certify and declare that the

foregoing statement and representations, and the schedules and representations on the reverse side hereof, constitute a true and accurate account of the

condition of this corporation as of the date first above written.

In witness whereof, I have hereunto affixed the corporate name and seal as the act and deed of said corporation.

(Corporate Seal)

(Please sign corporation name)

Date Signed

(Title)

OFFICERS

DIRECTORS

President

Vice-President

Treasurer

Secretary