Trustees or Directors:
Name
Address
City
State
Zip
Country
(If this space is insufficient, a complete list should be attached. Names and titles of officers must be listed exactly the same
throughout this application and all documents submitted with it.)
10. Is the corporation perpetual? Yes ____
No ____
If no, specific date of expiration: _________________ _____________
Month
Day
11. Provide a statement of the assets and liabilities dated within 12 months of the filing date.
Give specific date of statement: _________ ______ _____
Month
Day
Year
ASSETS
LIABILITIES AND SHAREHOLDERS' EQUITY
AMOUNT
TOTAL
AMOUNT
TOTAL
15. Accounts payable
1. Cash
16. Mortgages, notes, bonds
2. Trade notes & accounts receivable
payable in less than 1 year
- Less allowance for bad debts
17. Other current liabilities
3. Inventories
18. Loans from shareholders
4. Government obligations
19. Mortgages, notes, bonds
- U.S. and instrumentalities
payable in 1 year or more
- State, subdivisions thereof, etc.
20. Other liabilities
5. Other current assets
21. Total liabilities
6. Loans to shareholders
22. Capital stock:
7. Mortgage and real estate loans
- Preferred stock
8. Other investments
- Common stock
9. Buildings and other fixed
23. Paid-in or capital surplus
depreciable assets
24. Retained earnings - appropriated
- Less accumulated depreciation
25. Retained earnings income
10. Depletable assets
fund - unappropriated
- Less accumulated depreciation
26. Less cost of treasury stock
11. Land (net of any amortization)
27. Net worth (total
12. Intangible assets (amortizable only)
shareholders' equity)
- Less accumulated amortization
28. TOTAL LIABILITIES AND
13. Other assets
SHAREHOLDERS' EQUITY
14. TOTAL ASSETS
12. The corporation’s fiscal year closing date is: ___________
_______
Month
Day
I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct.
_______________________________________________________ __________ ___________ ________
Signature of president or vice president (circle one) EXACTLY as shown on previous page
Month
Day
Year
_______________________________________________________ __________ ___________ ________
Signature of secretary or assistant secretary (circle one) EXACTLY as shown on previous page
Month
Day
Year
Page 2 of 3