To the Fourth National Bank, of the City of New York.

Firm Name....................... Business............. . . .

Address....................................

For the purpose of procuring credit with the above bank for out negotiable paper, we furnish the following as being a fair and accurate state-ment of our financial condition on the............................day of

............... ...........190. . .

Assets

Liabilities

Cash ......................

Bills Payable for Mdse..

Bills Receivable, Good..

Bills Payable to Banks..

Accounts Receivable,

Good .................

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

I.oans or Deposits.

Merchandise (how valued)

Mtgs. or Liens on Real Estate..............

Real Estate in Name of Firm ..............

Other Indebtedness and of what

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

Machinery and Fixtures.

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

(Other Assets and of what composed

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

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

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

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

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

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

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

Total Liabilities..

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

Net Worth .. ..

Total............

Total ..................

State Last Date of taking Trial Balance Proof .........................

Regular Time of balancing Books.............................

Names of all General Partners........ .............................

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

Names of Special Partners with Amounts contributed by Each and until when. .

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

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Memorandum.......................................................

Please sign here................................

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