Financial Statement Page 2
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1
2SCHEDULE OF BONDS AND STOCKS
Non-Marketable Value
Marketable Value
Amount of Shares
Description (Extended Valuation in Column)
SCHEDULE OF REAL ESTATE
Description and Location
Cost
Actual Value
Mortgage Amount
Maturity Date
SCHEDULE OF NOTES PAYABLE
Specify any assets pledged as collateral, including the liabilities they secure:
To Whom Payable
Date
Amount
Due
Interest
Pledged as Security
The foregoing application (pages 1 through 5) has been carefully prepared, and the undersigned hereby solemnly declare(s) and
certify(s) that all the information contained herein is true and correct.
Date
19
Signature
_
Date
19
Signature
Rev. May/01
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