Cj^fcjMONWEALTH OF PENNSYL^i^^sllA PENNWLVANIA PUBLIC UTILITY COMMISSION P. O. BOX 3265. HARRISBURG. Pa. 1 7 1 20 October 5, 1988 IN REPLY PLEASE REFER TO OUR FILE Joseph Allan Shrecengost t/d/b/a Mt. Tabor Trucking R.D. //2, P.O. Box 181 Mayport, PA 16240 Re: Application of Joseph Allan Shrecengost Dear Mr. Shrecengost: We are returning the above referenced application and filing fee in the amount of $125.00 for the following reasons: (1) The trade name is registered to both Joseph Shrecengost and Susan Shrecengost; therefore, i f you are going to use the trade name of Mt. Tabor Trucking this application would have to be a partnership between Joseph and Susan Shrecengost. Attached are new application forms and a partnership agreement which would have to be completed. (2) If this application is just for Joseph Shrecengost, you would either have to amend the fictitious trade name to stand only in the name of Joseph Shrecengost or don't use the trade narae. (3) Attached is a copy of a sample caption that we believe accurately reflects the type of service which you will be rendering. If this is true, please initial the caption and return i t along with the correct application and information necessary so that we can process the application. Please feel free to call or write i f we can be of assistance, Sincerely, Enclosures Frances Walkinshaw Application Examiner Bureau of Transportation (717) 783-3037
To transport, as a contract carrier, by motor vehicle, wood, wood products and operating machinery, for Double Tree Lumber Co., between points in Pennsylvania,
RD#2, Box 181 Mayport, PA 1621^.0 rbvember 1 0, 1 988 Prances Walkinshaw Application Examiner PA Public Utility Oommission PO Box 3265 Harrisburg, PA 17120 fi Dear Ms. -Walkinshaw: Per telephone conversion of 11-10-88, I am returning enclosed application. An amendment was made to the fictitious trade name of Mt. Tabor Trucking removing the name of Susan Shrecengost. Upon checking with the Corporation Bureau, the amendment is listed on the computer but i t will be several weeks until the stamped certificate is returned as they are back-logged a couple of months. I was assured that the amendment could be verified by phone. Thank you. Sincerely, Joseph Shrecengost Mt. Tabor Trucking
r Form PUC 189 (Revised 11- BECEIVE BEFORE PENNSYLVANIA PUBLIC UTILITY ^ MMISSipp^g^ t A R Y S i 0 f F 7gg CD APPLICATION FOR MOTOR CARRIER C ERTIFIC ATKpR-* PER MIX CD <3; (SEE INSTRUCTIONS BEFORE PREPARING APPUCATION) In re: Application of for a certificate of public oonvenience or a permit evidencing the Commission's approval of the right and privilege of operating motor vehicles as a motor carrier for the transportation of PROPERTY. APPLICATION DOCKET No. /0ZV</D Folder No. COMPL; TO PENNSYLVANIA PUBLIC UTILITY COMMISSION: l t 2. Joseph Allan Shrecengost (Full and correct name of applicant) Mt. Tabor/Trucking (Trade na e, if any) MVIC The trade nam ei yhas been registered with the Secretary of the VJhfis or has not) CHECKED BY. J Commonwealth on 2/26/8? (attach copy of stamped registration form). TdateJ RD#2 PO Box 181 (Business Street Address) (P.O. Box, if any) Maypor t Arms trong (City) (County) (State) 4. Applicant's attorney (for this application) is: PA (Zip) I62lj.0 (Telephone) (Name) (Address) (Telephone) 5, Any notice, process or order of the PUC should be served upon: Joseph Shrecengost (Name) 6. Applicant does not (does or does not) and RD. no. 2 (Address) iciohfmoft or contract) FOtDE 1 EEC Mayport, PA 162i;0 hold Pa. PUC authority under Docket N. carrier. ^ObKhTED VU-WUATidN DOCKET - NOVU 1988
7. Applicant at Docket No. 1 ) 0 6 3 (does or does not) MC-202925 hold Interstate Commerce commission authority 8. Applicant is (check one): Individual. Partnership. Attach copy of partnership agreement and list names and addresses of partners below (use additional sheet if necessary). (Name) (Address) ^2 Corporation. 7, Organized under the laws of the State of_ and qualified to. do, business in Pennsylvania by registering with the Secretary of the Commonwealth on (Attach copy of Certificate of Incorporation or Authority and statement of charter purpose). Include as an attachment a list of corporate officers and their titles and the names, addresses and number of shares held by each stockholder. 9. Attach the following, as appropriate (check those attached): A Partnership Agreement. B Trade Name registration certificate. C Certificate of Incorporation or Authority. D Statement of corporate charter purpose. E List of corporate officers and stockholders.
THIS MUST BE COMPLETED BY NOTARY PUBLIC AFFIDAVIT OF APPLICANT (Natural Person) COMMONWEALTH OF PENNSYLVANIA firm ^ V ^ ^ o _County ss: y> \~\ H, tr^r v^r w t c-.p<v>. being duly swom (affirmed) according to law, deposes and says that the facts at tbeve set fortli are true and correct; or are true and correct to the best of his knowledge, information and belief and he expects to be able to prove the same at the hearing hereof. Swom and subscribed before me this d a y o f r^-vcm b>r.r- 19 My Commission Expires 2o -f- ^ ft.' / \ I Signature o Affianr Mr COMMISSIOK EXPIRES JUir 18 IMI Oath AFFIDAVIT OF APPLICANT (Corporation) COMMONWEALTH OF PENNSYLVANIA County ss: B, being duly swom (affirmed) according to law, deposes and says that he is of (Office of Affiant) (Name of. Corporation) ; that he is authorized to and does make this affidavit for it; and that the facts above set forth are true and correct; or are true and correct to the best of his knowledge, information and belief and that he expects the said at the hearing hereof. (Name of Corporation) to be able to prove the same Swom and subscribed before me this day of 19_ My Commission Expires Signature of Affiant Signature of Official Administering Oath
10. That the nature and character of the service to be rendered by applicant isthe transportation of property as a Common P3 Contract carrier by means of motor vehicles as follows: Wood, Wood Products and opera- -±lig machinery from Double Tree LumberCo., RD#3, Box 336A, Punxsutawney; PA 1576? (Henderson Twshp., Jefferson Cty.) to points in Pennsyl vani a^and from Points in Pennsylvania to Double Tree Lumber Co. 11. Applicant is not now engaged in any intrastate transportation of property for compensation in Pennsylvania (except as authorized by the'certificates of public convenience or permits specified in Paragraph 6) and will not engage-in the transportation for which approval is herein sought unless and until authorization for such transportation shall be received. CORPORATE SEAL Mt. Tabor Trucking (Print Name of Corporation, Partnership, Trade-Name or Individual)* Bys WD. k ij SignatureX \ ^ (Signature) (Signature) If a partnership, each partner must sign; if a corporation, at least one officer must sign, and corporate seal affixed.
To transport, as a contract carrier, by motor vehicle, wood, wood products and operating machinery, for Double Tree Lumber Co., between points in Pennsylvania.
'JSCB: 5^-311 (Rev. 831 FICTITIOUS NAME REGISTRATION CORPORATION BUKEAU IFJUNGFEE: QCoiporotu/lnJividual - Cotpotatiun 6A0.00 DEPARTWJENT OF STATE ^'aaiidividusl 525.00 308 NORTH OFFICE BUILDING 'tafcheck Enclosad HARRISBURG. PENNSYLVANIA 17120 Chorgo Account # In compliance with the requirements of Section 311 of Act 1982-295 (54 Pa. C.S. 311), this undersigned entity(ies) desiring to carry on or conduct a business in this Commonwealth under an assumed or fictitious name, style or designation, does (do) hereby certify that: $S5.00 1. Fictitious Name: v 2. Address of the principal place of business: (including street and number) (County) ( il^m-vu.rom< 3. 1 I P Brief statement of the character or nature of the business: 4. Individual or individuals interested in the business: (name and address) INAME) (NUMBER) (STREET) (CITYl (STATE) (ZIP CODE) 73 0 ri ^?,^ y ri p 5. Entity other than an individual interested in the business: (NAME) '" (FORM OF ENTITY) ORGANIZING, -*! \\ ri -M C - JURISDICTION ADDRESS IN JURIS. neglstercn OFFICE III tiny) 6. 1 am tamiliar with the provisions of Section 332 ol the Fictitious Names Act and understand that filing under tho Acl does not c/aate any exclusive or othor right to the fictitious name. 7. Agent! if any, authorized to execute amendments, withdrawals, or cancellations. IN TESTIMONY WHEREOF, the undersigned have caused this registration to be executed this?~) 3 D '/>/!.0(4'/ ^W/'{<('-f> ; /fya f)- Individual Hay of )- n t) y Individual [\dividugl Corporate Seal Nama of Corporalion Secretory of Assistant Secretarv Prusidenl of Vice President Corporate Seal Name ol Corporalion 030 FILED Sacrutary of Assistant Secretnry FEB 2 G 1987 President or Vice President - FOR OFFICE USE ONLY - 002 CODE 003 REV BOX SEQUENTIAL NO. 100 MICROFILM NUMBER REVIEWED BY 004 SICC AMOUNT 00 i CORPORA TION NUMDCR DATE APPROVED $ Q//1IL/D ATE REJECTED CERTIFY TO INPUT BY LOG IN LOG IN (REFILE! Sociotary of the Commonwealth Dopartmont of State Commonwealth of Pennsylvania MAILED BY DATE REV. l^l&l OTHER &p VERiFlEp BY LOG OUT LOG OUT (REFILE) A
AGREEHliM THIS AGREEMENT is made this ^Oth j]ay oi' SoP^}^, 1 9fi^ between JOSEPH SHRECENGOST/DBA MT, TABOR TRUOKIHO (carrier) an individual Nhose bu 3 ine as addrcjsu is RD-^, Ksiyport, \?k 1 62l\.l and DOUBLE TREK LUMBER CO. ( shinper ) vr-iose busings/a a^idross is HDfr^j Box 33^ Punrsutavnrcy, PA^ 1!i??67 I PREMISES A. CARRIER holds common carrier 1 authori ty j?rom tho Inters tafce Coraiiiorco Commis.sion at Docket Ho. MC-202925 which a\i:taoriz«s i t o perform certain t r an s po r t a/b i o n soryicr; by mo tpr* vehicle, 3. CARRIER OKI SHIPPER wish bo comply with tha rulos and regulations ol the ICC and PUC and hav?> tho re fore entire* d into tl'iis agraemont. TERMS AND. C0MDIT10N3 ' 1. SHIPPER will tender to CARRIER for transportation within the scope of CARRIER 1 S operating authority a minimum of on?; load of..lumber per month durinfr the timo that this contract is in t-'f fee t. 2. CARRIER will charge SHIPPER and SHIPPER will pay to CARRIER for any transportation performed under this Agreement in accordance with the conditions^ rates and charges specified in CARRIER'S Schedule of rates which are set forth in Appendix "A" hereto and incorporated herein by reference. Shipper will pay CARRIER the rates and char rve s on or before 30 days after receipt of CARRIER'S billing statement. 3. CARRIER will accept for transportation such shipment an SHIPPER shall, pursuan t to the terms of this Agreement and wi thin the capabili ties and le^al rights of the CARRIER, call upon CARRIER to trams oort.
!.. In the transportation or SHIPPER' 3.Ooigh'b, CMRi'METi shall have the aa.ma liability Ji'or loss or '-Ian]ago to SHIPPER'S freight as i t does while operating as a oommon carrier under IOC* This Agreement shall become effective.from the date of execution and shall remain in effect from year to year subject to the provisions of Paragraph 7 here-in concerning the Thirty (30) day advance notice of cancellation. 6. This y^reement shall be binding upon the parties and thei r sue c e a s or s and a JJ si gns. 7. This Agreement can be cancelled by either party upon thirty (30J days advance written notice to the othor party. I l l EXECUT10H IN WITNESS WHEREOF,.the parties here toi; intending to be lo gaily bound hereby, have hereunto set their hands the day and year firs t above written. MT. TABOR TRUCKING.i i finseph A, Shrecenpjoat DOUBLE TREE LUMBER CO
^^mroix»a" IGHDJiM-ilLOX' 1 RATES :p 100.00 minimmn char go $ 2.00 per mile for firs b 100 miles $ 1.85 per mile for 101 miles to 1 $0 miles:inclusive!> ijj 1.75 per mile for 151 miles to 200 miles 1.65 per mile for 201 miles to 250 miles $ 1-55 per mile for 251 miles to 300 miles Above rates based upon load weight up to and including 000.:bs An additional $.10 per 1000 lbs. will be charged on weig hta over 14].,,000 lbs.
December 2, 1988 IN REPLY PLEASE REFER TO OUR FILE Joseph Allan Shrecengost, t/d/b/a Mt. Tabor Trucking R.D. 2 P.O. Box 181 Mayport, PA 16240 In re: A-00108440 - Application of Joseph Allan Shrecengost, t/d/b/a Mt. Tabor Trucking Dear Sir: The application filed by you has been captioned as attached and will be submitted for review provided no protests are filed on or before December 27, 1988. If protests are filed, you will be advised as to further procedure. You are further advised that the above application will be published in the Pennsylvania Bulletin of December 3, 1988. Very truly yours. David Ehrhart Supervisor - Application Section Bureau of Transportation DE:RP:11 DOCKETED APPLICATION DOCKET DEC 51988 ENTRY No.
A-00108440 JOSEPH ALLAN SHRECENGOST, t/d/b/a MT. TABOR TRUCKING (R.D. //2, P.O. Box 181, Mayport, Armstrong County, PA 16240) - contract carrier - wood, wood products and operating machinery, for Double Tree Lumber Co., between points in Pennsylvania.
PENNSYLVANIA PUBLIC UTILITY COMMISSION SERVICE OF NOTICE OF MOTOR CARRIER APPLICATIONS DATE SERVICE DEC -3 1988 BUREAU OF TRANSPORTATION CONTRACT CARRIER NOVEMBER 1988 A-O0108440 Application of Joseph Allan Shrecengost, t/d/b/a Mt. Tabor Trucking, for the right to begin to transport, as a contract carrier, by motor vehicle, wood, wood products and operating machinery, for Double Tree Lumber Co., between points in Pennsylvania. FW:rs 11/18/88 Application received: 11/15/88 Application docketed: 11/17/88 DOCKETED APPLICATION DOCKET DEC 51988, ENTRY No.
PENNSYLVANIA PUBLIC UTILITY COMMISSION RECEIPT The addressee named herouncibr has paid Pennsylvania Public Utiliiy Commission lot iho lollowing bill, subjecl to linal colleciion ol check or money order tendered lor such paymenl. Mt. Tabor Trucking R.D. #2, Box 161 Mayport, PA 16240 ate December 13, 1988 CR 131394 A In re application of Mt. Tabor Trucking A-00108440 $125.00 Revere accoun, 003^80-017601-103 (ok) Ck 240262t3iecks S125.00 Currency Ulility account. 50T26 JoBonh MoJRinger For Department ol Revenue
COMMONWEALTH OF PENNSYLVANIA PENNRj LVANIA PUBLIC UTILITY COMgifctSION P. O 32B5. HARRISBURG. Pa. 1 ; 20 December 30, 1989 IN REPLY PLEASE REFER TO OUR FILE James Allan Shrecengost P. 0. Box 181 Mayport, PA 16240 In re: A-00108440 - Application of James Allan Shrecengost, Mt Tabor Trucking t/d/b/a Dear Sir: The above referenced application has been assigned to me for review without oral hearing. In order to reach a determination on the application, you are being requested to file a verified statement in accordance with 52 Pa. Code 3.381(e)(1). You are required to file: VERIFIED STATEMENT OF APPLICANT The verified statement should be in paragraph form. Each heading contained in the enclosed minimum outline should be a separate section or paragraph. All questions must be answered. You are being granted an initial period of thirty (30) days in which to file the required statement. The statements are due in this office on or before: JANUARY 31, 1989. If additional time is required, it may be requested by telephone but must be followed by a request in writing, with the reason(s) for the extension. Questions about your application may be directed to me by telephoning 717-787-4386. End. DOCUMENT if \ J..-.^ Very truly yours, 3- Lawrence Keener-Farley, Esq. Technical Review Section Bureau of Transportation DOCKETED APPLICATION DOCKET JAN 1 31989 ENTRY No._
JOSEPH ALLAN-" SHRECENGOST d/b/a/ MT. TABOR TRUCKING January 27, 1989 Mr. Lawrence Keener-Farley, Esq. Technical Review Section Bureau of Trasnportation COMMONWEALTH OF PENNSYVANIA PENNSYLVANIA PUBLIC UTILITY COMMISSION P.O. Box 3265 Harrisburg, Pa. 17120 Subject: Dear Mr. Keener A-001 08440 - Verifiech statement Farley: In accordance with your letter of December 30th, 1988 and in compliance with 52 Pa. Code 3.381(e) (1), we are enclosing herewith the Verified Statement of Joseph Allan Shrecengost, d/b/a/ Mt. Tabor Trucking. Trusting we a re in full", comp liance we are Si ncerely yours, JOSEPH ALLAN SHRECENGOST d/b/a/ MT. TABOR TRUCKING Mt. Tabor Road, Box 181 Mayport, PA 16240 with your re quest, 1 an Shrecengost JAS/vtm Enclosure
3 BEFORE' Th PENNSYLVANIA PUBLIC UTILITY COMMISSION VERI RIED^STrAT-EMENTiiOFjiARRLI CANT JOSEPH ALLAN SHRECENGOST t/d/b/a/ MT. TABOR TRUCKING p.u.c. #A-ooiomo I. LEGAL NAME AND DQMICl : lie! rorfflbrhicantif'fe^^'^pfi'c T The applicant is Joseph Allan Chrecengost, t/d/b/a/ Mt. Tabor Trucking domiciled at Mt. Tabor Road, Box 181, Mayport, Pa. 16240. II. IDENTIFICATION AND QUALlFICATION..OF;-PERSON MAKINGS THIS STATEMENT!" My name is Joseph Allan Shrecengost, d/b/a Mt. Tabor Trucking. I am the owner of Mt. Tabor Trucking, a sole proprietorship. My duties require me to participate in the formulation of common policy, the conduct of the company operations, publishing tariffs and the presentation of evidence before the Pennsylvania Public Utility Commission and other regulatoryragencies. I am submitting this statement on behalf of Mt. Tabor Trucking. III. AFFIiUIATIOK.WliTH.OTjHERr CARRIERS I have no affiliated with otherfcarriers. IV: AUTHORITY SOUGHT By this application, Joseph Shrecengost, d/b/a/ Mt. Tabor Trucking seeks authority to operate as a contract carrier, by motor vehicle, over irregular routes in the transportation of Wood, Wood-Eat^ ducts and operating machinery between Double Tree Lumber C o m PP n yd0cketed R. D. #3, Box 336A, Punxsutanwey, PA_-i&76-7~(Hend^sin \Townsl1ip? P f! L n I M T, 0 N D 0 C K E J m '.l, 301989 - IENTRY No. A^W ' Jefferson County) and points in Penns\ylv6a^4^V^,B,,,,s " \. I - I
V. GENERAL SCOPE OF CURRENTLY AUTHORIZED OPERATIONS Joseph Shrecengost, d/b/a/ Mt. Tabor Trucking is a motor common carrier holding authority from the Interstate Commerce Commission certificated at MC 202925 to operate as a common carrier, by motor vehicle, in interstate or foreign commerce, over irregular routes, transporting general commodities (except classes A and B explosives, household goods, and commodities in bulk) between points in CT, DE, IL, IN, I A, KY,, MD, rma^ml, MN, MO, Nil I, NY, NC, OH, TN, VA, WV, WI, PA AND Rl. (Appendix A attached) VI. DUPLICATING AUTHORITY/WHICH.WILL.RESUL'TrFROM GRANT OF GRANT OF AUTHORITY There will be no duplicating authority as a result of the grant of this authority. VII. DUAL OPERATIONS RESULTING FROM GRANT OF AUTHORITY T The grant of this authority will not result in dual operations for Mt. Tabor Trucking. VIM. PERTINENT TERMINAL FAClLliTIES AND COMMUNICATIONS NETWORK Applicant, Joseph Shrecengost, d/b/a/ Mt. Tabor Trucking maintains one terminal and could extend service between points in the application area. We are located on a site that houses our administrative operation and said location is capable of holding our entire tractor and trailer inventory. Additionally, our facility is capable of performing the maintenance operations and any, major repairs are completed by a tractortdiesel repair shop within a 3 mile distance. With reference to our equipment, we have suitable equipment and am fully capable of acquiring additional equipment on short notice to meet future needs for servicing the territory enchanced^
VIII. PERTINENT TERMINAL FACILTITIES AND COMMUNICATIONS NETWORK - Continued; in this application. IX PERTINENT EQUIPMENT EQUIPMENT OWNED: 1976 CMC Truck Unit #762 1977 C Chevrolet Tractor Unit #771 1985 Freightliner Tractor Unit #851 1987 Freightliner Tractor Unit #871 1988 Freightliner Tractor Unit #881 TRAIUERS 1977 Fruehauf Flat Unit #406 1983 Ti-Brook Flat Unit 454 1986 Fruehauf Flat Unit #420 1986 Rogers Lowboy Unit #510 1987 FontainerFlat Unit #455 1987 Fontainer Lowboy Unit #421 X. SAFETY-', PROGRAM i In conducting its business, Mt. Tabor Trucking^hasb developed and instituted an active safety and preventative maintenance program under the supervision and direction of a maintenance foreman. We have implemented a program to insure that our employess are familiar with and more importantly, in compliance with all applicable Department of Transportation regulations. Likewise, this program insures that Mt. Tabor Trucking's equipment is maintained and operated in the safest possible manner. Consequently, we are in compliance with those regulations and are not under any safety investigations at this time. Applicant maintains insurance coverage in compliance with
x - SAFETY PROGRAM - Continued the requirements set forth by the Commission. XI. TYPE OF SERVICE TO BE OFFERED Applicant will commit sufficient units of equipment to this shipper to transport his product between his facilities and points in Pennsylvania. Applicant will make timely deliveries, spot equipment for the shipper's use and provide a service designed to meet the distinct transportations needs of the shipper. XII. FINANCIAL DATA See Exhibit A - attached. XIII. WHETHER SERVICE PROVIDED WILL CREATE EMPTY MILES OR BACKHAUL This service will not create empty mileage for the carrier in fact, quite the reverse will be true. In returning to our terminal or passing through the borough of Punxsutawney, Pa. we will be able to drop equipment or pick up the load which will reduce empty miles. We have equipment passing through several points in Pennsylvania and could likewise have loaded miles on return to Punxsutawney, Pa. Punxsutawney, Pa. locates in very close proximity (12 miles) from our terminal and thus is stragetically located to make for more efficient transportation. XIV. DESCRIBE SHIPPER AND STATE THE TYPES OF COMMODITIES TO BE TRANSPORTED'- 1 i-i!* tshipper, Double Tree Lumber Company, ships lumber to several points in Pennsylvania. Double Tree Lumber has a sawmill which provides pallet lumber, blocking, 2 x 4's and boards to lumber yards. The lumber yards do further refinement of the. lumber and in turn sell the end product to retail stores.
XV. ANY OTHER INFORMATIQN DEEMED PERTINENT. Joseph Shrecengost, d/b/a/ Mt. Tabor Trucking will offer and provide the contract'.carriage identified in this application. Applicant will make allocation of equipment for the shipper's exclusive use and provide efficient and expeditious service between its place of business and points in Pennsylvania. Applicant maintains sufficient trucks, tractors, flatbediand lowboys to ensure the continued availability of sevice to this contract shipper. The equipment which will be utilized in this contract carriage is stationed or housed within a very short distance from the shippers place of business. Applicant is committed to serve this contract shipper should this applicant be granted. Joseffh Shrecengost, d/b/a Mt. Trucking Owner Tabor
THIS MUST BE COMPLETED BY NOTARY PUBLIC AFFIDAVIT OF APPLICANT (Natural Person) COMMONW-EALTH OF PENNSYLVANIA Clar.ion -County ss: Joseph Allan Shrecengost < b e i n g d u l y s w o r n (affirmed) according to law, deposes and says that the facts above set forth are true and correct; or are true and correct to the best of his knowledge, information and belief and he expects to be able to prove the same at the hearing hereof. Swom and-aubscribed before me this ^7 day o My C4f tes.-'otafty PUSLfc! )RdO<3fl. CUHION tuun IV MY COMMISSION EXPIRES MARCH 18,1991 Momber. Pennsylvania Assodaacn ol Notof ios ^/ Signature of Affiant Joseph Allan Shrecengost d/b/a/ Mt. Tabor Trucking Signature of Official Administering Oath AFFIDAVrr OF APPLICANT (Corporation) COMMONWEALTH OF PENNSYLVANIA : - County : ss: being duly swom (affirmed) according to Uw, deposes and says that he Is of (Office of Affiant) " ; that he is authorized to and does make this (Name of Corporation) affidavit for it; and that the facts above set forth are true and correct; or are true and correct to the best of his knowledge, information and belief and that he expects the said to be able to prove the same (Name of Corporation) at the hearing hereof. Swom and subscribed before me this day of 19_ My Commission Expires Signature of Affiant Signature of Official Administering Oath
4 EXHIBIT A CUD FINANCIAL STATEMENT PERSONAL NAME -A Q g^c- ^ \"\ ^ \ \ r C C ' e Ki Cr-\ r-. TV A' ADDRESS STATEMENT FORM SUGGESTED BY FKDKNAU RKSENVC BANK OF CL4CVELAND BUSINESS OR OCCUPATION TO THE CONDITION. ON A-^.^r^.i... 19.1.1 FILL IN DATE 4 «ASSETS OOiXAN* C*MTB LIAB1UITES CASH ON HAND a r CASH IN BANK r i f NOTES PAYABLE TO BANKS-UNUCUNID. NOTES RECEIVABLE»KU«n> ir HOITSAOI - v NOTES REC El V Afl LE OTHE I wtu ucutu NOTES PAYABLE-OTHER THAN TO BANKS-UHUCUIED ' N \ NOTES REC IVABLE-UHUaiiC8 ACCOUNTS RECEIVABLE NOT DUE Or ACCOUNTS PAYABLE Or NOTES PAYABLE WITH SECURITY OTHER THAN REAL ESTATE (IUM11C»«i) N\ ACCOUNTS RECEIVABLE PAST DUE LOANS ON LIFE INSURANCE O M = 0. S. GOVT. OBLIGATIONS TAXES 'V STOCKS. BONDS, AND OTHER INVESTMENTS UNCLUDC FUND) IN MJUUNG OR UVMGl AND LOAN COMPANIU) Otiwiu FACC i) ANY OTHER INDEBTEDNESS DUE WITHIN ONE YEAR \ SO Ts CASH VALUE UFE INSURANCE or MORTGAGES OR LIENS ON REAL ESTATE (utmue MLOW) \ C'.K\ C- fteal ESTATE (IHHIU ULOW) ANY OTHER INDEBTEONCSS-DUE BEYOND ONE YEAR ^ CJ NJ r ANY OTHER ASSETS-IUHIU So no n (Of ) 7 *6S -\" r\, c K Tr AC A, * r r«f TOTAL. LIABILITIES NET WORTH ^ T r ^ r -! c" r.v TOTAI. TOTAL IEAL ESTATE OWNED oxacmmon *xo LOCATION YITLC IN MMOSK N*Mt IMPHOWCO OR loa^a-^aa Shtt-rr-MCvt o 1 S i VM.U1 tft* VM.UK IHWKWICX ^J.' ' v ^ CONTINGENT LIABILITY OF ANY KIND (IP NONE. SO INDICATE) UPON NOTES OR ACCOUNTS RECEIVABLE DISCOUNTED SOLO. OR ASSIGNED A* GUARANTOR FOR OTHERS ON NOTES. BONOS. CONTRACTS, ETC. ANV OTHER CONTINGENT Ll AHILlTY ITEM I2E TOTAL CONTINOENT LIAOILITIES SEC OTHKM SIOS
IKS. BONDS, AND OTHE" I N V EST MEN" OKiemrrioM AMOUWT AMOUNT SCHEDULE OF LIABILITIES SECURED BY ASSETS OTHER THAN REAL ESTATE NAMI or cntoirom AMOUNT DCBCN1PTION Or BECUHITV AMOUNT or SKCUMITT I J STATEMENT OF NET WORTH AND INCOME AND EXPENSES FOR THE PERIOD BEGINNING 19 AND ENDING. FILL IN DATES.19 < «NET WORTH AT CLOSE OF PREVIOUS YEAR ADD INCOME FOR PERIOD AS ABOVE FROM FOLLOWING SOURCES: SALARIES, WAGES. COMMISSIONS. FEES, ETC INCOME {OR LOSS) FROM BUSINESS OR PROFESSION INCOME (OR LOSS) FROM PARTNERSHIPS. SYNDICATES. POOLS. ETC. RENTS AND ROYALTIES PROFIT (OR LOSS) ON INVESTMENTS INCOME FROM INVESTMENTS - OTHER INCOME-ITEMIZE. TOTAL INCOME FOR PERIOD TOTAL. DEOUCT-EXPENSES PAID, TAXES PAID-FEDERAL INCOME S OTHER J INTEREST PAID OTHER DEDUCTIONS ITEMIZE TOTAL DEDUCTIONS FOR PERIOD NET WORTH AT CLOSE OF PERIOD (MUST AGREE WITH NET WORTH ON PAGE I). ALL QUESTIONS SHOULD BE ANSWERED LIST ASSETS. PLEDGED OR HYPOTHECATED OTHER THAN AS STATED A DOVE ARE THERE ANY JUDGMENTS UNSATISFIED OR SUITS PENDING AGAINST YOU? AMOUNT I. LIFE INSURANCE CARRIED I NAME OF BENEFICIARY CASH VALUE I _ STATE MAXIMUM AMOUNT BORROWED FROM ALL SOURCES AT ANY ONE TIME DURING YEAR J 1 DATE. STATE MINIMUM AMOUNT BORROWED FROM ALL SOURCES AT ANY ONE TIME DURING YEAR THC UNDERSIGNeO HEREBY CERTIFIES THAT THE POREOOINO STATEMENT HAS BEEN CAREFULLY READ BY THE UNDCRSIONEO. THAT IT IB A TRUE AND CORRECT STATEMENT OF THE UNOERSIONED'S FINANCIAL CONDITION, AND THAT IT IS DELIVERED TO YOU FOR THE FUR- FOSE OF FNOCURIMO CREDIT FROM TIME TO TIME. IN THE EVENT OF ANY SUBSTANTIAL ADVERSE CMANOC IN THE UNDERSIONED'S FINAN- CIAL CONDITION. THE UNDERSIGNED WILL OIVE YOU PftOMFT NOTICE THEREOF. THE POftEOOINa 19 A STATEMEMT OF MY FINANCIAL CONDITION OH OATE SIGNED. SIGN HERE