FIS 0553 (10/09) Office of Financial and Insurance Regulation page 1 of 2 Route to: Securities Section Date of balance sheet Personal Balance Sheet MM / DD / YY Prepare in accordance with generally accepted accounting principles (GAAP) to show the current financial condition of the applicant. Add footnotes to this statement, describing all contingent liabilities such as note endorsements, warranties, pending litigation, etc. Income can be shown in accounts receivable if it has been earned and not yet received. Method of valuation used: Use same method for all assets Please attach any documentation which may explain or support a particular entry; i.e., IRS repay agreements. Space is provided on page 2 for notes. Attach additional sheets if necessary. Name of Applicant Market value Cost CRD Number CURRENT LIABILITIES CURRENT ASSETS (read "Notes for items 1-5" at bottom of column) 1. Cash 20. Automobile Loan(s) 2. Checking/Savings 21. Credit Card Debt(s) 3. Stocks, Bonds, Mutual Funds (see note below) 22. Personal Loans 4. IRA, 401K, Keogh (vested interest) 23. Student Loans 5. Life Insurance (cash surrender value only) 24. Personal Estimated Taxes Payable: 6. Accounts Receivable (must explain on page 2) 25. Real Estate Estimated Taxes Payable: 7. Primary Residence 26. Other Estimated Taxes Payable: 8. Other Residence 27. Contingent Liabilities Mortgages Payable: 9. Real Estate - Rental Property 10. Automobiles 28. 11. Furniture 29. 12. Collectibles 30. 13. Antiques 31. 14. Jewelry Liens/Judgments: (list all separately) 15. 32. 16. 33. 17. 34. 18. 35. 19. TOTAL ASSETS (add lines 1 through 18) 36. Compromise with creditor balance 37. All other liabilities including but not limited to Insurance Payable, Accounts Payable, Chapter Notes for items 1-5: Supporting documentation is required Provide supporting documentation for each item listed on lines 1-5. Dates of the supporting documents must match the date of the balance sheet. Amounts must match supporting documentation or attach a sheet that shows how the amounts were calculated. 13 balance (must itemize and explain on page 2) 38. TOTAL LIABILITIES (add lines 20 through 37) 39. NET WORTH (subtract line 38 from line 19) Please complete page 2 of this Balance Sheet American LegalNet, Inc. www.FormsWorkFlow.com FIS 0553 (10/09) Office of Financial and Insurance Regulation page 2 of 2 Use this section for footnotes to balance sheet entries and for additional explanations as requested in instructions. Reference each footnote by its corresponding line number from page one of this form. Attach additional sheets if necessary. Certification This balance sheet, including all footnotes and attachments is a true, complete and correct statement of my financial condition as of the date indicated on page one of the balance sheet. Signature Date signed Daytime telephone number (please include area code) Email address Signer's name (typed or printed) PA 551 of 2008 requires submission by each applicant. Failure to properly complete and file this form may result in denial or revocation of your license, or other compliance action. Send completed form to: By US Mail: By Delivery Service to: OFIR - Securities PO Box 30701 Lansing, MI 48909-7724 OFIR - Securities 3rd Floor 611 W. Ottawa Street Lansing, MI 48933 Michigan Department of Energy, Labor & Economic Growth DELEG is an equal oppportunity employer/program. Auxiliary adis, services and other reasonable accommocations are available upon request to individuals with disabilities. Visit OFIR online at: www.michigan.gov/ofir Phone OFIR toll-free at: 1-877-999-6442 American LegalNet, Inc. www.FormsWorkFlow.com