Form 703 - Application For Emergency Or Temporary Authority - To Transport Passenger Or Household Goods Page 2

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10. List all other motor carrier companies which hold Indiana Intrastate Authority in which each shareholder has an inter-
est; indicate the number of shares held by that shareholder:
Motor Carrier Company
Certifi cate or Permit No.
Shareholder
Number of Shares
□
□
11. Is applicant currently in bankruptcy?
Yes
No
□
□
Has applicant ever fi led for bankruptcy?
Yes
No
If yes, indicate cause number, date of fi ling and in what court fi led: ________________________________________
____________________________________________________________________________________________
12. Has any shareholder, partner or owner of applicant ever been a shareholder, partner or owner of a motor carrier which
has fi led bankruptcy?
□
□
Yes
No
If yes, complete the following:
Name of Shareholder,
Motor Carrier
Date of Bankruptcy
Cause Number of
Court Filed In
Partner or Owner
Petition
Bankruptcy Petition
□
□
Did any motor carrier listed above hold Indiana Intrastate Authority?
Yes
No
If yes, indicate certifi cate or permit number: ______________________________________
What was the disposition of the certifi cate or permit as a result of the bankruptcy?
___________________________________________________________________________________________
___________________________________________________________________________________________
□
□
Did that motor carrier list the State of Indiana as a creditor?
Yes
No
If yes, state what debt was owed and whether the debt was discharged or paid pursuant to a reorganization?
___________________________________________________________________________________________

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