Indiana Department of Revenue CIG-1FS R/5-02 State Form 49375 Financial Statement From Office Address Branch Offices Business Location of Plant To For the purpose of obtaining loans and discounting paper with you, and otherwise procuring credit from time to time, we for the following, which is and is shown, by our books to be a true and accurate state of our financial condition on _________________ ________. We agree to and will notify you immediately in writing of any Year materially unfavorable change in our financial condition. In the absence of such notice or of a new and full written statement, this may be considered as a continuing statement and substantially correct; and it is hereby expressly agreed that upon application for further credit, this statement shall have the same force effect as if delivered as an original statement of our financial condition at the time such further credit is requested. (Fill all Blanks. Writing “No” or “None” where necessary to complete information.) Assets Liabilities Thousands Hundreds Thousands Hundreds Ones Ones Bills (Notes) Payable Given for Merchandise Bills (Notes) Payable Negotiated to Banks Secured Unsecured Bills (Notes) Payable Otherwise Disposed of Open Accounts Payable. Not Due “ “ ‘ Past Due Deposits of Money with Us Bills and Accounts Payable (To Officers and/or stockholders) Bonded Debt (When due ___________________) Mortgage Debt “ “ Security Interest in Personal Property Reserves (Itemize) Other Liabilities and of What Composed Other Assets and of What Composed Cash on Hand and in Bank Bills (Notes) Receivable, Good, Due from Customers Accts. Receivable, Good, Due from Customers L.L. Bonds and other Government Securities Merchandise Finished (How Valued _______) “ Unfinished (How Valued _______) “ Raw Material (How Valued _______) Total Quick Assets Machinery and Fixtures Town or City Real Estate and Buildings Country Real Estate _______ Acres at $_____ Investments: Bonds and Stocks (List on reverse side hereof) Bills Receivable, Doubtful (Face Value $___________) Estimated Worth Bills and Accounts Receivable (Due from officers and/or stockholders) Total Liabilities Capital Surplus Including Undivided Profits Total Specify Any of Above Assets Pledged as Collateral Total Specify Any of Above Liabilities Secured as Collateral Contingent Liability: Notes Receivable of Customers Discounted or Sold and Not included in assets enumerated above Other Contingent Liability (Specify) We have not pledged or assigned any of the above accounts receivable. Our assigned accounts receivable amount to Insurance: On Merchandise $ Buildings $ Machinery $ Total Insurance Life Insurance Payable to Corporation $ Business and Results: Annual Sales for the year ended Year to Year or from Year Gross Profits on Sales For the Same Period Expense of Conducting Business “ “ “ “ Net Profit “ “ “ “ Other Income including investments “ “ “ “ Dividends Paid for the period Year to Year Capital: Authorized (Par Value $ per share) Issued $ How Paid in: Cash $ Other Property $ Total Incorporated under the laws of what state? Bank Accounts: Where kept Mortgages and Bonds: On what assets a lien Average terms on which we Sell Average Terms on which we Buy Time of Year when Notes and Accounts Receivable of Customers, Uncollected, are generally maximum Time of Year when Stocks of Merchandise on hand are generally maximum Minimum Time of Year when Liabilities are maximum Minimum Statement: Is it based on actual inventory? If so, Date Verification: Have the books been audited by a Certified Public Accountant? If so, Name and Date of Audit. (OVER) Minimum American LegalNet, Inc. www.FormsWorkflow.com REAL ESTATE Description Improvements Value Assessed Cash Mortgages Equity Whose Name is Title to above real estate held? Real Estate held in Fee Simple, Leasehold or Under Contract? LIST OF STOCKS AND BONDS OWNED Name of Corporation Location Par Value Actual Value Date of Last Dividend or Interest Rate Nature of Business Other Data Affiliated Concerns I, the undersigned officer of this corporation, acquainted with its affairs and duly authorized to contract liabilities, hereby certify and declare that the foregoing statement and representations, and the schedules and representations on the reverse side hereof, constitute a true and accurate account of the condition of this corporation as of the date first above written. In witness whereof, I have hereunto affixed the corporate name and seal as the act and deed of said corporation. (Corporate Seal) (Please sign corporation name) Date Signed 20 By (Title) OFFICERS DIRECTORS President Vice-President Treasurer Secretary (Statements submitted to Federal Reserve Bank must either be signed originals or certified copies. If copies are furnished, following certificate must be officially signed by member bank.) We hereby certify that the foregoing is a true and correct copy of a signed financial statement of the above mentioned individual, firm or corporation now on file in this bank. (Name of Member Bank) (Official Signature) (Title) (Statements certified by certified public accountants may, in the discretion of the Executive Committee of the Federal Reserve Bank, be accepted.) American LegalNet, Inc. www.FormsWorkflow.com