Ps Form 5472 - Pre-Award Questionnaire And Assets And Liabilities Statement Page 2
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1
2Name
Date (As of)
Assets and Liabilities Statement
Assets
Liabilities
Amount
Name, Location or Description
Basis for Loan
Amount
or Value
Cash In
Bank
Notes
Stocks
and
Bonds
Chattel
Notes
Mortgage
Real
Real
Estate
Estate
Mortgage
Vehicles
Taxes
Other
Other
Total Assets
Total Liabilities
The undersigned authorizes the U.S. Postal Service to make such inquiries as necessary to determine my financial responsibility
and capability for performing under the proposed contract based on the pre-award survey information provided.
Signature
Title
Date
5472,
PS Form
April 2006 (Reverse)
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Parent category: Life