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FINANCIAL STATEMENT FOR BUSINESSES

DE 926C Rev. 15 (7-19) (INTERNET)Page 1 of 4 CUFINANCIAL STATEMENT FOR BUSINESSESNOTE: Complete all blocks except Dept. Use Only blocks. Write N/A (not applicable) in those blocks that do not Payroll Tax Account Number:Business Phone:Federal Employer Identification Number:Name and Address of BusinessoSole Proprietor _____oPartnership_____oCorporation State of Inc.:_____Date of Inc.: _____CA Corp. ID No. _____oOtherName, title, and phone number of person completing FINANCIAL StatementType of BusinessList Owner, Partners, Officers, Major Shareholder, and TitleEffective DateHome AddressPhone NumberLast 4 Digits of SSND river License AssetsCash on Hand$Bank Accounts: Include Savings and Loans, Credit Unions, Line of Credit, of InstitutionAddressType of AccountsAccount NumberBalance$Accounts/Notes ReceivableNameAddressAmount$Securities: Stocks, Bonds, Mutual Funds, Money Market Funds, Government Securities, or DenominationWhere LocatedValue$Dept.

Repossessions . o Yes o No Participation or beneficiary to trust, estate, etc. o Yes o No Explanation: Anticipated increase in business income . o Yes o No If answer is YES, give following information: Source Date increase is expected and frequency

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