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t=1A9At�GIAL STATEMENT <br /> 1 Statement of Financial Condition OFA —Sc.. <br /> 8_ e�rI le15 <br /> (individual Name or ame of siness Being Qualified,as appropriate.) <br /> Date of Financial Statement ' SSNIFEID Number <br /> ASSETS(Omit Cents) LIABILITIES(Omit Cents) <br /> 1. Cash in Bank –Refer to $ <br /> statement on previous page 14_ Accounts Payable> $ <br /> regarding verification of cash in <br /> bank. <br /> 2_ Accounts and Notes $ 15. Notes Payable fa Banks <br /> Receivable $ <br /> °�� i (2,.2 and Others(i.e.,vehicles! . <br /> 3. Inventory,i.e.,supplies $ equipment/lines of creditetc. <br /> r 16_ Mortgages and Bonds $ <br /> 4_ US Government Securities $ 17. Unpaid Taxes <br /> $ <br /> 5- Other Current Assets,Le-, $ <br /> vehicles itemize 18_ Wages&Interest $ <br /> � 19. Other Liabilities <br /> if corporation) $ ` <br /> 6. Real Estate $ <br /> 7_ Buildings-Net $ <br /> after depreciation <br /> 8. Machinery, Fixtures& $ <br /> Equipment <br /> (after depreciation) <br /> 9. Leasehold Improvements- $ <br /> Net after amortization <br /> 10. Cash Surrender Value of $ <br /> Life Insurance <br /> 11.Stock&Bonds $ �� <br /> 12. Other Assets $ <br /> itemize <br /> J. Total Assets(add items 1 $ 2tB. Total <br /> thru 12 above Liabilities(add items $ r <br /> 14 thru 19 above <br /> = 21. Net Worth (Subtract Item $ <br /> 20 from Item 13.) <br /> TOTAL frorn Line 13 <br /> $ TOTAL LIABILITIESINET $ > <br /> WORTI�–Add lines 20 and 21 '7( j:7' <br /> PLEASE NOTE THAT THE TOTAL ASSETS COLUMN AND TOTAL LlABlL1TIES/NET 4NORTH COLUMN MUST <br /> EQUAL THE SAME AMOUNT_ <br />