State Form 1349 - Financial Profile - 2010

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Indiana Grain Buyers &

FINANCIAL PROFILE

OFFICE USE ONLY

Warehouse Licensing Agency

State Form 1349 (R6 / 2-10)

One North Capitol Avenue

Approved by State Board of Accounts, 2006

Suite 600

FILE #

Indianapolis, Indiana 46204

Phone: (317) 232-1356

Fax: (317) 232-1362

INFORMATION HEREIN WILL REMAIN CONFIDENTIAL

INSTRUCTIONS: Please complete this form and attach to Financial Statement

PER INDIANA STATUTE I.C. 26-3-7-6.5

COMPANY INFORMATION

Name of business:

d/b/a:

Individual in charge:

Title of Individual in charge:

Address (location and mailing):

City, State, ZIP Code:

County:

Telephone number (Area code):

Fax number (Area code):

PRINCIPLE BUSINESS

FORM OF BUSINESS ORGANIZATION

BUSINESS TYPE

ACTIVITIES

Check

only one:

Grain

Grain Bank

Proprietorship

Corporation (Regular)

Grain & Feed

Warehouse

Partnership

Cooperative

Seed

Grain Buyer

“S” Corporation

Popcorn

Grain Buyer & Warehouse

Other, specify: _____________

Other, specify: _________________________________________

Fiscal Closing Date

Date of Incorporation

(month, day, year)

Accounting Basis:

Cash

Accrual

Owner’s name and address (if proprietorship), Partners (if partnership), or Officers and Directors ( in the case of corporations).

Attach separate list if necessary

Name:

Percent owned (to total 100%)

If corporation, (check one box)

Director

Officer

Address:

Title:

Name:

Percent owned (to total 100%)

If corporation, (check one box)

Director

Officer

Address:

Title:

Name:

Percent owned (to total 100%)

If corporation, (check one box)

Director

Officer

Address:

Title:

Name:

Percent owned (to total 100%)

If corporation, (check one box)

Director

Officer

Address:

Title:

APPLICANT’S VERIFICATION

I, (Name):

__________________________________________________________________________

being first duly sworn, depose and say that I am

the (Title):

__________________________________________

of the licensee (Name of Company):

______________________________________

authorized on the part of said company to verify and file with the Indiana Grain Buyers and Warehouse Licensing Agency this financial profile; that I have full

personal knowledge of the matters set forth herein and that all of the same are true in substance and in fact.

Signature:

Date

(month, day, year)

The above verification must be signed by the owner if an individual, by one of the partners if a partnership,

or by an officer of the corporation if a corporation.