Form 12a639 - Statement Of Fimamcial Condition For Businesses - 2004 Page 2

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Page 2
SECTION I—GENERAL FINANCIAL INFORMATION (continued)
12. Real property
Brief Description and Type of Ownership
Address (Include county and state)
a.
b.
c.
d.
13. Life insurance policies owned with business as beneficiary
Policy
Face
Available Loan
Name Insured
Company
Type
Number
Amount
Value
TOTAL (Enter in Item 19)
14. Additional information regarding financial condition (Court proceedings, bankruptcies filed or anticipated, transfers of assets for less than full value,
changes in market conditions, etc.; include information regarding company participation in trusts, estates, profit-sharing plans, etc.)
15. Accounts/notes receivable (Include loans to stockholders, officers, partners, etc.)
Date Due
Name
Address
Amount Due
Status
TOTAL (Enter in Item 18)

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