Balance Sheet

Statement of Financial Condition: (Applicant)

Attach annual report, audited financial report or report prepared for other regulatory agencies

Finacial Statement: (Required by the Michigan Department of Consumer & Industry Services)

Please provide a copy of your most current balance sheet or have your bookeeper complete and sign form below.

Information stated below is confidential and will be viewed only by the fund administrator and Bureau.

Current Year

STATEMENT OF ASSETS & LIABILITIES

Assests:

Current Assets


Other Assets
Properties, Building & Equipment
Good Will
Other
Total Assets

Liabilities

Other Liabilities

Capital

Signature

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number