MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS 3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 573-751-4231 www.labor.mo.gov/DWC IT IS REQUIRED THAT THE FINANCIAL STATEMENT BE FOR THE SELF-INSURED ENTITY ONLY AND SHALL BE EXECUTED ON THIS FORM. ALL FINANCIAL INFORMATION MUST BE AUDITED. YOU MAY ATTACH AN ANNUAL REPORT OR AUDITED INTERNAL FINANCIAL STATEMENT WITH ACCOUNT DETAILS. HOWEVER, SUMMARY FIGURES MUST BE ON THIS REPORT. FINANCIAL STATEMENTS FOR THE PARENT MAY NOT BE SUBSTITUTED FOR THE SUBSIDIARY'S INDIVIDUAL FINANCIAL INFORMATION UNLESS PRIOR APPROVAL HAS BEEN GIVEN BY THE DIVISION. Self-Insurer's Annual Financial Statement This is a confidential report to the Division of Workers' Compensation for the purpose of showing financial ability to pay worker's compensation liabilities as a self-insurer under Section 287.280 Workers' Compensation Law Employer Name _______________________________________________ Employer Address _________________________________________ _________________________________________ Fiscal Year Ending _________________________________________ Figures are in Name of Auditing Firm or Individual _____________________________________________ _________________________________________ (Denomination) Assets Current Assets Cash and Cash Equivalents. . . . . . . . . . . . . . . . . . $_______________________ Short Term Investments . . . . . . . . . . . . . . . . . . . . $_______________________ Notes Receivable Net (less discount) . . . . . . . . . . $_______________________ Accounts Receivable Net . . . . . . . . . . . . . . . . . . . $_______________________ Inventory (itemized or enter total on this form and attach detail) ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ Total Inventory . . . . . . . . . . . . . . . . . . . $_______________________ Deferred Income Taxes. . . . . . . . . . . . . . . . . . . . . $_______________________ Other Current Assets (itemized or enter total on this form and attach detail) ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ Total Other Assets. . . . . . . . . . . . . . . . . $_______________________ Total Current Assets $_______________________ Long-Term Assets Fixed Assets Net of Depreciation (itemized or enter total on this form and attach detail) ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ Total Fixed Assets. . . . . . . . . . . . . . . . . $_______________________ Deferred Assets . . . . . . . . . . . . . . . . . . . . . . . . . . . $_______________________ Intangible Assets/Goodwill Net of Amortization . $_______________________ Other Assets (itemized or enter total on this form and attach detail) ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ Total Other Assets. . . . . . . . . . . . . . . . . $_______________________ Total Long Term Assets $_______________________ TOTAL ASSETS $ ______________________ ______________________ WC-85 (10-11) AI American LegalNet, Inc. www.FormsWorkFlow.com Liabilities and Net Worth Current Liabilities Accounts Payable . . . . . . . . . . . . . . . . . . . . . . . . . $_______________________ Accrued Liabilities . . . . . . . . . . . . . . . . . . . . . . . . $_______________________ Other Current Liabilities (itemized or enter total on this form and attach detail) ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ Total Other Liabilities. . . . . . . . . . . . . . $_______________________ Total Current Liabilities $_______________________ Long-Term Liabilities Long Term Debt . . . . . . . . . . . . . . . . . . . . . . . . . . $_______________________ Deferred Income Taxes. . . . . . . . . . . . . . . . . . . . . $_______________________ Other Long Term Liabilities (itemized or enter total on this form and attach detail) ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ Total Other LT Liabilities . . . . . . . . . . . $_______________________ Total Long Term Liabilities $_______________________ TOTAL LIABILITIES $_______________________ Net Worth Itemize net Worth or enter total on this form and attach detail ________________________________ ________________________________ ________________________________ TOTAL NET WORTH $_______________________ TOTAL LIABILITIES AND NET WORTH $ ______________________ ______________________ Total Revenues _______________________________ Net Income __________________________________ Name of Officers President _________________________________ Treasurer _________________________________ STATE OF __________________________________ COUNTY OF _______________________________ Vice-President ________________________________ Secretary ____________________________________ } SS ________________________________________________ , being duly sworn, says that he/she is the ___________________________________ of the above-named employer, self-insured pursuant to Section 287.280 of the Missouri Workers' Compensation Law, that he/she has carefully examined the foregoing report and the facts therein set forth are true; that the assets are correctly set forth and there are not other liabilities against the employer than those set forth therein; that it is a report of the self-insured employer, exclusive of subsidiaries or affiliates. Sworn to before me, this _______ day of _________________, ______ _________________________________________________________ (Notary Public) ___________________________________________________ (Signature) (My commission expires _____________________________________) NOTE ­ If the employer is a corporation, signature should be made and seal used according to the laws of Missouri and the official taking this acknowledgment is cautioned to see that it is properly taken. Do not omit official title of affiants, if corporation. WC-85-2 (10-11) AI American LegalNet, Inc. www.FormsWorkFlow.com