Full Form

To the........................Bank of........................

Corporate or Firm Name..........................................

Location ............................................

Business.............................................

Branches, if any......................................

For the purpose of procuring credit with the above bank for our negotiable paper, we furnish the following statement of our financial condition on the ........................day of........................190...

The Trial Balance of our Books is as follows:-

Assets

Liabilities

Cash on Hand and in Bank. .

Capital .......................

Bills Receivable ................

Surplus, or Profit and

Loss .........................$

Accounts Receivable .............

Merchandise in Hands of

Consignees ............

Bills Payable, for Merchandise ..........$

Merchandise finished, on

Hand.............$

(how valued)

Bills Payable to own

Banks ..........................$

Pills Payable for Paper sold..............$

Merchandise unfinished, on Hand .................

(how valued)

Open Accounts .................

Loans or Deposits .............

Bonded Debt. (Date of Maturity,)............

Real Estate in Name of Company of Firm .(Cost ofabove)

Mortgages or I.iens on Real

Estate ...............

Present Market Value, $)

Chattel Mortgages ..............

Machinery and Fixtures (not included in Real Estate . .

Other Liabilities (state in detail).

Office Furniture and fixtures (not included in Real Estate)

Other Assets (state in detail).

Specify any of above Assets pledged as Collateral.

Specify any of above Liabilities secured by Collateral.

Capital and surplus, as shown by Trial Balance.........................

$

Add Interest due company or Firm............................................

$

Other Assets, not included in Trial Balance (state in detail).

Deduct, Salaries due and accrued, Labor, Rent, etc. (estimated )........................................................................ .$

Interest on Bonded Debt ( due and accrued )..................... .$

,, due, other than above.............................. $

Bills or Accounts Receivable considered doubtful............ $

Other Liabilities, not included in Trial Balance (state in detail)....................................$

Balance Net Assets over Liabilities...........................................

$

Contingent Liability

Accommodation Indorsements............$

Indorsed Bills Receivable Outstanding........................$

For Corporations

Capital

Authorized......$

Subscribed......$

Paid in.........$

( as per Trial Balance. )

Held by Co. as Treasury Stock . $ How paid in: -

Cash ................. $

Other Property........ $

Description of above Property and how valued....................

Incorporated in what State and under what General Law or Special act . .

Date of Charter ...... ...........

Officers

Address

Pres.......................

Vice- Pres.....................

Sec'y.....................................

Treas...........................

Directors

..............................

............................

...............................

Are stockholders liable beyond Amount

Subscribed ?

...............................................................

Rate per cent and Amount of Dividends paid during Preceding Year.

....................................................

For Firms

Individual Worth of Respective Partners outside the Business.

Names in full of all general

Partners

Names in full of Special Part ners, with Amounts contributed by Each and until when.

Connection of Each Partner in

Other Business, if any.

Time Present Firm has been in

Business.

Succeeded the Frm of.........

Amount withdrawn by Partners during Preceding Year.

Amount of Annual Sales.............................................

Amount of Annual Expenses..........................................

Amount of Accounts and Bills Receivable past due.......................

Extended or renewed, if any.......................................

Insurance carried on Merchandise, $..........On Real Estate, $..........

Amount and Maturity of Largest Indebtedness during Present Year (exclusive of Bonded Indebtedness of Corporation)....................

Was Last Inventory Actual ? If so, by whom taken and Date..............

If Estimate, by whom made and date...............................

Regular Times of taking Inventory.....................................

Regular Times of balancing Books.....................................

Object for which Proceeds of our Paper is wanted........................

(Sign Company or Firm Name)............................

By........................................

Date........................

Indorsement No.......

Statement of of

Remarks

Discount Committee.