PREQUALIFICATION FINANCIAL STATEMENT
(See Sections 2.2 and 3.2)	
Name of Company or Individual:	     	Date (as of):	     	
ASSETS		LIABILITIES	
	Name, Location, or Description	Amount
or Value		Basis for Loan	Amount	

Cash in Bank			

Notes			

Stocks
and
Bonds						

Notes			

Chattel
Mortgage			

						

Real
Estate			

Real
Estate
Mortgage			

						

Vehicles			

Taxes			

						

Other			

Other			

						
	Total Assets			Total Liabilities		
The undersigned authorizes the U.S. Postal Service to make such inquiries as necessary to determine my financial responsibility and capability to be prequalified as a highway transportation service provider based on the prequalification survey information provided herein.	
	Title:       	Date:       	

SMTP Form 5472-PQ, May 2003