Form 12a639 - Statement Of Fimamcial Condition For Businesses - 2004 Page 3

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Page 3
SECTION II—ASSET AND LIABILITY ANALYSIS
(c)
(b)
(a)
(d)
(e)
Cur. Mkt.
Liabilities
Amt. of
Value
Asset or Liability
Description
Bal. Due
Mo. Pymt.
16. Cash on hand
17. Bank accounts
18. Accounts/Notes receivable
19. Life insurance loan value
20. Real property
a.
b.
c.
d.
21. Vehicles (Model, year
a.
and license)
b.
c.
22. Machinery and equipment
a.
(Specify)
b.
c.
23. Merchandise inventory
a.
(Specify)
b.
a.
24. Other assets (Specify)
b.
a.
25. Other liabilities
b.
(Include notes
c.
and judgments)
d.
e.
f.
g.
26. Federal taxes owed
27. State taxes owed
28. TOTAL
SECTION III—INCOME AND EXPENSE ANALYSIS
29. The following information applies to income and expenses during the
30. Accounting method used
period ________________________ to _________________________
Income
Expenses
31. Gross receipts from sales, services, etc.
37. Materials purchased
32. Gross rental income
38. Net wages and salaries
33. Interest
39. Rent
34. Dividends
40. Installment payments
35. Other income (Specify)
41. Supplies
42. Utilities/Telephone
43. Gasoline/Oil
44. Repairs and maintenance
45. Insurance
46. Current taxes
47. Other (Specify)
36. TOTAL
48. TOTAL
49. Net difference
(Item 36 minus Item 48)
CERTIFICATION—Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities and other
information is true, correct and complete.
50. Signature
51. Date

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