Form 703 - Application For Emergency Or Temporary Authority - To Transport Passenger Or Household Goods Page 4
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517. In support of this application, applicant submits the following exhibits, attached hereto and made part hereof.
Exhibit A
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A statement describing applicant’s fi nancial status, including a brief statement of assets and liabilities
as of the date of application, and a copy of applicant’s most recent balance sheet and income statement.
Exhibit B
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A certifi cate from the Secretary of State of Indiana showing applicant is registered to do business in
Indiana (if the applicant is a non-resident corporation);
or
A certifi cate of existence from the Secretary of State of Indiana (if the applicant is an Indiana corporation).
Exhibit C
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If applicant is currently in bankruptcy, a copy of the bankruptcy petition.
Exhibit D
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Copies of all Indiana intrastate certifi cates or permits refl ecting authority granted there in.
WHEREFORE, applicant asks the Indiana Department of Revenue to authorize applicant to operate motor vehicles over
the public highways of the state as set forth herein.
DATED THIS ___________ DAY OF _____________________ , 20 _________ .
____________________________________
(Applicant’s Signature)
____________________________________
(Print Applicant’s Name)
____________________________________
(Title)
_____________________________________________
(Signature of Attorney)
_____________________________________________
(Print Name of Attorney)
_____________________________________________
(Address)
_____________________________________________
_____________________________________________
(Telephone Number)
_____________________________________________
(Email Address)
STATE OF _____________
)
)
COUNTY OF ____________ ) SS:
Before me the undersigned, a Notary Public for ____________________ County, State of ______________,
personally appeared ________________, and he being fi rst duly sworn by me upon his oath, says that the facts
alleged in the foregoing instrument are true. Signed and sealed this ______ day of _______________, 20 _____.
____________________________________
(Signature) Notary Public
____________________________________
(Printed Name)
County of Residence: ________________________ My Commission Expires: __________________
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