Company Name

Fiscal Year Ended:

President:

Name

Chief Financial Officer:

Name

Secretary:

Name

Other:

Name

Present Directors:

Name

Name

Name

Shareholders:

Name

Name

Name

 

Has there been a change of Officer or Director? (If yes, fill in information below, i.e. effective dates, new, resigned or removed?)

Has there been a change of Shareholder? (If yes, fill in information below, i.e. transfer, additions or redemption of shares?)

Has the Corporation borrowed any money or made any loans to the Shareholders, Officers, Directors,         Banks or any other lending institutions? Explain:

Has the Corporation leased any property? Any personal property over $12,000 Annual? Explain:

Has the Corporation Purchased or sold any real property? Any personal property over $9,500? Explain:

Did the Corporation act as a Guarantor for the Obligation of any person or entity? Explain:

Has there been any change of salaries, bonuses paid or payable to each Officer, Director or Shareholder of the Corporation? Explain:

Has there been any dividends paid or payable? Explain:

Has the Corporation secured NEW disability or Medical Insurance? New Life Insurance? Explain:

Information relating to the dates and amounts of contributions to any pension or profit sharing plans, and other employee benefit programs established by the corporation: