Form Et 18 - Close Corporation Valuation Form - Ohio Department Of Taxation Page 2
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4ET 18
Rev. 7/03
Page 2
Item III. Statement of Earnings
The following is a statement of the profi t or loss (after income tax but before dividends) for the last fi ve years indicated and
also a statement representing earnings per share for said common stock:
Based on following number
Net profi t (or loss)
a
Earnings per share
b
Year ending
of shares then outstanding
(a)
(b)
Do not deduct any dividends paid during year.
To arrive at the earnings per share for common stock, deduct dividend requirements of preferred
stock and divide remainder by the number of shares of common stock then outstanding.
Item IV. Sales Evidence
The following is a list of the sales of the corporate stock, made within a reasonable period of time prior to and/or after the
date of death.
Shares Sold
Seller
Buyer
Broker
Common/Preferred
Number
Date
Price
Item V. Incorporation Data
Incorporated under the state of
When
Principal place of business (street address, city, state, ZIP code)
Nature of business (If additional space is needed, use Additional Comments section on page 3.)
President
Vice president
Treasurer
Secretary
being fi rst duly sworn deposes and says that he/she is the
President,
Vice president,
Treasurer,
Secretary of the corporation and that he/she has examined the books and records
of said company that disclose the above facts; that the same represents a true copy of the records of said corporation.
Signature of offi cer
Title
Sworn to and subscribed before me this
day of
, 20
.
Notary public
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