EX-99.5 6 a12-12647_1ex99d5.htm EX-99.5

Exhibit 99.5

 

 

Monthly Operating Report

 

 

CASE NAME: Tri-Flow, Inc.

ACCRUAL BASIS

 

 

CASE NUMBER: 12-31553-bjh-11

 

 

 

JUDGE:

Barbara J. Houser

 

 

UNITED STATES BANKRUPTCY COURT

 

NORTHERN AND EASTERN

DISTRICT OF

TEXAS

 

DIVISION 6

 

MONTHLY OPERATING REPORT

 

MONTH ENDING: April 30th, 2012

 

IN ACCORDANCE WITH TITLE 28, SECTION 1746, OF THE UNITED STATES CODE, I DECLARE UNDER PENALTY OF PERJURY THAT I HAVE EXAMINED THE FOLLOWING MONTHLY OPERATING REPORT (ACCRUAL BASIS-1 THROUGH ACCRUAL BASIS-7) AND THE ACCOMPANYING ATTACHMENTS AND, TO THE BEST OF MY KNOWLEDGE, THESE DOCUMENTS ARE TRUE, CORRECT AND COMPLETE. DECLARATION OF THE PREPARER (OTHER THAN RESPONSIBLE PARTY): IS BASED ON ALL INFORMATION OF WHICH PREPARER HAS ANY KNOWLEDGE.

 

 

RESPONSIBLE PARTY:

 

 

 

 

 

/s/ John H. Homier

 

CFO

ORIGINAL SIGNATURE OF RESPONSIBLE PARTY

 

TITLE

 

 

 

John H. Homier

 

5/21/2012

PRINTED NAME OF RESPONSIBLE PARTY

 

DATE

 

 

 

 

 

 

PREPARER:

 

 

 

 

 

/s/ Adrian Lamberti

 

Controller

ORIGINAL SIGNATURE OF PREPARER

 

TITLE

 

 

 

Adrian Lamberti

 

5/21/2012

PRINTED NAME OF PREPARER

 

DATE

 



 

 

Monthly Operating Report

 

 

CASE NAME: Tri-Flow, Inc.

ACCRUAL BASIS-1

 

 

CASE NUMBER: 12-31553-bjh-11

 

 

 

COMPARATIVE BALANCE SHEET

 

 

 

 

SCHEDULE

 

MONTH

 

MONTH

 

MONTH

 

 

 

AMOUNT

 

3/31/2012

 

April 2012

 

 

 

ASSETS

 

 

 

 

 

 

 

 

 

1.

UNRESTRICTED CASH

 

 

 

 

 

 

 

 

 

2.

RESTRICTED CASH

 

 

 

 

 

 

 

 

 

3.

TOTAL CASH

 

$

0

 

$

0

 

$

0

 

$

0

 

4.

ACCOUNTS RECEIVABLE (NET)

 

 

 

 

 

 

 

 

 

5.

INVENTORY

 

 

 

 

 

 

 

 

 

6.

NOTES RECEIVABLE

 

 

 

 

 

 

 

 

 

7.

PREPAID EXPENSES

 

 

 

 

 

 

 

 

 

8.

OTHER (1)

 

$

250,000

 

 

 

 

 

 

 

9.

TOTAL CURRENT ASSETS

 

$

250,000

 

$

0

 

$

0

 

$

0

 

10.

PROPERTY, PLANT & EQUIPMENT

 

 

 

 

 

 

 

 

 

11.

LESS: ACCUMULATED DEPRECIATION / DEPLETION

 

 

 

 

 

 

 

 

 

12.

NET PROPERTY, PLANT & EQUIPMENT

 

$

0

 

$

0

 

$

0

 

$

0

 

13.

DUE FROM INSIDERS

 

 

 

 

 

 

 

 

 

14.

OTHER ASSETS - NET OF AMORTIZATION (ATTACH LIST)

 

 

 

 

 

 

 

 

 

15.

OTHER (ATTACH LIST)

 

 

 

 

 

 

 

 

 

16.

TOTAL ASSETS

 

$

250,000

 

$

0

 

$

0

 

$

0

 

POSTPETITION LIABILITIES

 

 

 

 

 

 

 

 

 

17.

ACCOUNTS PAYABLE

 

 

 

 

 

 

 

 

 

18.

TAXES PAYABLE

 

 

 

 

 

 

 

 

 

19.

NOTES PAYABLE

 

 

 

 

 

 

 

 

 

20.

PROFESSIONAL FEES

 

 

 

 

 

 

 

 

 

21.

SECURED DEBT

 

 

 

 

 

 

 

 

 

22.

OTHER (ATTACH LIST)

 

 

 

 

 

 

 

 

 

23.

TOTAL POSTPETITION LIABILITIES

 

 

 

$

0

 

$

0

 

$

0

 

PREPETITION LIABILITIES

 

 

 

 

 

 

 

 

 

24.

SECURED DEBT

 

 

 

 

 

 

 

 

 

25.

PRIORITY DEBT

 

 

 

 

 

 

 

 

 

26.

UNSECURED DEBT

 

 

 

 

 

 

 

 

 

27.

OTHER (ATTACH LIST)

 

 

 

 

 

 

 

 

 

28.

TOTAL PREPETITION LIABILITIES

 

$

0

 

$

0

 

$

0

 

$

0

 

29.

TOTAL LIABILITIES

 

$

0

 

$

0

 

$

0

 

$

0

 

EQUITY

 

 

 

 

 

 

 

 

 

30.

PREPETITION OWNERS’ EQUITY

 

 

 

 

 

 

 

 

 

31.

POSTPETITION CUMULATIVE PROFIT OR (LOSS)

 

 

 

 

 

 

 

 

 

32.

DIRECT CHARGES TO EQUITY (ATTACH EXPLANATION)

 

 

 

 

 

 

 

 

 

33.

TOTAL EQUITY

 

$

250,000

 

$

0

 

$

0

 

$

0

 

34.

TOTAL LIABILITIES & OWNERS’ EQUITY

 

$

250,000

 

$

0

 

$

0

 

$

0

 

 


 

(1) Consolidated retainer for Cano Petroleum, Inc. and its related debtor entities

 



 

 

Monthly Operating Report

 

 

CASE NAME: Tri-Flow, Inc.

ACCRUAL BASIS-2

 

 

CASE NUMBER: 12-31553-bjh-11

 

 

INCOME STATEMENT

 

 

 

MONTH

 

MONTH

 

MONTH

 

MONTH

 

 

 

3/8/2012 thru 3/31/2012

 

April 2012

 

 

 

 

 

REVENUES

 

 

 

 

 

 

 

 

 

1.

GROSS REVENUES

 

 

 

 

 

 

 

 

 

2.

LESS: RETURNS & DISCOUNTS

 

 

 

 

 

 

 

 

 

3.

NET REVENUE

 

$

0

 

$

0

 

$

0

 

$

0

 

COST OF GOODS SOLD

 

 

 

 

 

 

 

 

 

4.

MATERIAL

 

 

 

 

 

 

 

 

 

5.

DIRECT LABOR

 

 

 

 

 

 

 

 

 

6.

DIRECT OVERHEAD

 

 

 

 

 

 

 

 

 

7.

TOTAL COST OF GOODS SOLD

 

$

0

 

$

0

 

$

0

 

$

0

 

8.

GROSS PROFIT

 

$

0

 

$

0

 

$

0

 

$

0

 

OPERATING EXPENSES

 

 

 

 

 

 

 

 

 

9.

OFFICER / INSIDER COMPENSATION

 

 

 

 

 

 

 

 

 

10.

SELLING & MARKETING

 

 

 

 

 

 

 

 

 

11.

GENERAL & ADMINISTRATIVE

 

 

 

 

 

 

 

 

 

12.

RENT & LEASE

 

 

 

 

 

 

 

 

 

13.

OTHER (ATTACH LIST)

 

 

 

 

 

 

 

 

 

14.

TOTAL OPERATING EXPENSES

 

$

0

 

$

0

 

$

0

 

$

0

 

15.

INCOME BEFORE NON-OPERATING INCOME & EXPENSE

 

$

0

 

$

0

 

$

0

 

$

0

 

OTHER INCOME & EXPENSES

 

 

 

 

 

 

 

 

 

16.

NON-OPERATING INCOME (ATT. LIST)

 

 

 

 

 

 

 

 

 

17.

NON-OPERATING EXPENSE (ATT. LIST)

 

 

 

 

 

 

 

 

 

18.

INTEREST EXPENSE

 

 

 

 

 

 

 

 

 

19.

DEPRECIATION / DEPLETION

 

 

 

 

 

 

 

 

 

20.

AMORTIZATION

 

 

 

 

 

 

 

 

 

21.

OTHER (ATTACH LIST)

 

 

 

 

 

 

 

 

 

22.

NET OTHER INCOME & EXPENSES

 

$

0

 

$

0

 

$

0

 

$

0

 

REORGANIZATION EXPENSES

 

 

 

 

 

 

 

 

 

23.

PROFESSIONAL FEES

 

 

 

 

 

 

 

 

 

24.

U.S. TRUSTEE FEES (1)

 

 

 

 

 

 

 

 

 

25.

OTHER (ATTACH LIST)

 

 

 

 

 

 

 

 

 

26.

TOTAL REORGANIZATION EXPENSES

 

$

0

 

$

0

 

$

0

 

$

0

 

27.

INCOME TAX

 

 

 

 

 

 

 

 

 

28.

NET PROFIT (LOSS)

 

$

0

 

$

0

 

$

0

 

$

0

 

 


Note 1 - This fee is being paid by Cano Petroleum, Inc. as this company has no bank account or accounting system to record and make payments.

 



 

 

Monthly Operating Report

 

 

CASE NAME: Tri-Flow, Inc.

ACCRUAL BASIS-3

 

 

CASE NUMBER: 12-31553-bjh-11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MONTH

 

MONTH

 

MONTH

 

QUARTER

 

 

 

3/8/2012 to 3/31/2012

 

April 2012

 

 

 

TOTAL

 

CASH RECEIPTS AND DISBURSEMENTS

 

 

 

 

 

 

 

 

 

1.

CASH - BEGINNING OF MONTH

 

$

0

 

$

0

 

$

0

 

 

 

RECEIPTS FROM OPERATIONS

 

 

 

 

 

 

 

 

 

2.

CASH SALES

 

 

 

 

 

 

 

 

 

COLLECTION OF ACCOUNTS RECEIVABLE

 

 

 

 

 

 

 

 

 

3.

PREPETITION

 

 

 

 

 

 

 

 

 

4.

POSTPETITION

 

 

 

 

 

 

 

 

 

5.

TOTAL OPERATING RECEIPTS

 

$

0

 

$

0

 

$

0

 

$

0

 

NON-OPERATING RECEIPTS

 

 

 

 

 

 

 

 

 

6.

LOANS & ADVANCES (ATTACH LIST)

 

 

 

 

 

 

 

 

 

7.

SALE OF ASSETS

 

 

 

 

 

 

 

 

 

8.

OTHER (ATTACH LIST)

 

 

 

 

 

 

 

 

 

9.

TOTAL NON-OPERATING RECEIPTS

 

$

0

 

$

0

 

$

0

 

$

0

 

10.

TOTAL RECEIPTS

 

$

0

 

$

0

 

$

0

 

$

0

 

11.

TOTAL CASH AVAILABLE

 

$

0

 

$

0

 

$

0

 

$

0

 

OPERATING DISBURSEMENTS

 

 

 

 

 

 

 

 

 

12.

NET PAYROLL

 

 

 

 

 

 

 

 

 

13.

PAYROLL TAXES PAID

 

 

 

 

 

 

 

 

 

14.

SALES, USE & OTHER TAXES PAID

 

 

 

 

 

 

 

 

 

15.

SECURED / RENTAL / LEASES

 

 

 

 

 

 

 

 

 

16.

UTILITIES

 

 

 

 

 

 

 

 

 

17.

INSURANCE

 

 

 

 

 

 

 

 

 

18.

INVENTORY PURCHASES

 

 

 

 

 

 

 

 

 

19.

VEHICLE EXPENSES

 

 

 

 

 

 

 

 

 

20.

TRAVEL

 

 

 

 

 

 

 

 

 

21.

ENTERTAINMENT

 

 

 

 

 

 

 

 

 

22.

REPAIRS & MAINTENANCE

 

 

 

 

 

 

 

 

 

23.

SUPPLIES

 

 

 

 

 

 

 

 

 

24.

ADVERTISING

 

 

 

 

 

 

 

 

 

25.

OTHER (ATTACH LIST)

 

 

 

 

 

 

 

 

 

26.

TOTAL OPERATING DISBURSEMENTS

 

$

0

 

$

0

 

$

0

 

$

0

 

REORGANIZATION EXPENSES

 

 

 

 

 

 

 

 

 

27.

PROFESSIONAL FEES

 

 

 

 

 

 

 

 

 

28.

U.S. TRUSTEE FEES

 

 

 

 

 

 

 

 

 

29.

OTHER (ATTACH LIST)

 

 

 

 

 

 

 

 

 

30.

TOTAL REORGANIZATION EXPENSES

 

$

0

 

$

0

 

$

0

 

$

0

 

31.

TOTAL DISBURSEMENTS

 

$

0

 

$

0

 

$

0

 

$

0

 

32.

NET CASH FLOW

 

$

0

 

$

0

 

$

0

 

$

0

 

33.

CASH - END OF MONTH

 

$

0

 

$

0

 

$

0

 

$

0

 

 



 

 

Monthly Operating Report

 

 

CASE NAME: Tri-Flow, Inc.

ACCRUAL BASIS-4

 

 

CASE NUMBER: 12-31553-bjh-11

 

 

 

 

SCHEDULE

 

MONTH

 

MONTH

 

MONTH

 

ACCOUNTS RECEIVABLE AGING

 

AMOUNT

 

3/8/2012 to 3/31/2012

 

April 2012

 

 

 

1.

0-30

 

 

 

 

 

 

 

 

 

2.

31-60

 

 

 

 

 

 

 

 

 

3.

61-90

 

 

 

 

 

 

 

 

 

4.

91+

 

 

 

 

 

 

 

 

 

5.

TOTAL ACCOUNTS RECEIVABLE

 

$

0

 

$

0

 

$

0

 

$

0

 

6.

AMOUNT CONSIDERED UNCOLLECTIBLE

 

 

 

 

 

 

 

 

 

7.

ACCOUNTS RECEIVABLE (NET)

 

$

0

 

$

0

 

$

0

 

$

0

 

 

AGING OF POSTPETITION TAXES AND PAYABLES 

MONTH:

April 2012

 

 

 

 

 

 

 

 

 

 

 

 

 

0-30

 

31-60

 

61-90

 

91+

 

 

 

TAXES PAYABLE

 

DAYS

 

DAYS

 

DAYS

 

DAYS

 

TOTAL

 

1.

FEDERAL

 

 

 

 

 

 

 

 

 

 

 

2.

STATE

 

 

 

 

 

 

 

 

 

 

 

3.

LOCAL

 

 

 

 

 

 

 

 

 

 

 

4.

OTHER (ATTACH LIST)

 

 

 

 

 

 

 

 

 

 

 

5.

TOTAL TAXES PAYABLE

 

$

0

 

$

0

 

$

0

 

$

0

 

$

0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

ACCOUNTS PAYABLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS OF POSTPETITION TAXES

MONTH:

April 2012

 

 

 

 

BEGINNING

 

AMOUNT

 

 

 

ENDING

 

 

 

 

TAX

 

WITHHELD AND/

 

AMOUNT

 

TAX

 

 

 

 

LIABILITY*

 

0R ACCRUED

 

PAID

 

LIABILITY

 

FEDERAL

 

 

 

 

 

 

 

 

 

1.

WITHHOLDING**

 

 

 

 

 

 

 

 

 

2.

FICA-EMPLOYEE**

 

 

 

 

 

 

 

 

 

3.

FICA-EMPLOYER**

 

 

 

 

 

 

 

 

 

4.

UNEMPLOYMENT

 

 

 

 

 

 

 

 

 

5.

INCOME

 

 

 

 

 

 

 

 

 

6.

OTHER (ATTACH LIST)

 

 

 

 

 

 

 

 

 

7.

TOTAL FEDERAL TAXES

 

$

0

 

$

0

 

$

0

 

$

0

 

STATE AND LOCAL

 

 

 

 

 

 

 

 

 

8.

WITHHOLDING

 

 

 

 

 

 

 

 

 

9.

SALES

 

 

 

 

 

 

 

 

 

10.

EXCISE

 

 

 

 

 

 

 

 

 

11.

UNEMPLOYMENT

 

 

 

 

 

 

 

 

 

12.

REAL PROPERTY

 

 

 

 

 

 

 

 

 

13.

PERSONAL PROPERTY

 

 

 

 

 

 

 

 

 

14.

OTHER (ATTACH LIST)

 

 

 

 

 

 

 

 

 

15.

TOTAL STATE & LOCAL

 

$

0

 

$

0

 

$

0

 

$

0

 

16.

TOTAL TAXES

 

$

0

 

$

0

 

$

0

 

$

0

 

 


*

The beginning tax liability should represent the liability from the prior month or, if this is the first operating report, the amount should be zero.

**

Attach photocopies of IRS Form 6123 or your FTD coupon and payment receipt to verify payment or deposit.

 



 

 

Monthly Operating Report

 

 

CASE NAME: Tri-Flow, Inc.

ACCRUAL BASIS-5

 

 

CASE NUMBER: 12-31553-bjh-11

 

 

The debtor in possession must complete the reconciliation below for each bank account, including all general, payroll and tax accounts, as well as all savings and investment accounts, money market accounts, certificates of deposit, government obligations, etc. Accounts with restricted funds should be identified by placing an asterisk next to the account number. Attach additional sheets if necessary.

 

 

MONTH:    

April 2012

 

BANK RECONCILIATIONS

 

 

 

Account #1

 

Account #2

 

Account #3

 

 

 

A. BANK:

 

 

 

 

 

 

 

 

 

B. ACCOUNT NUMBER:

 

 

 

 

 

 

 

 

 

C. PURPOSE (TYPE):

 

 

 

 

 

 

 

TOTAL

 

1.

BALANCE PER BANK STATEMENT

 

 

 

 

 

 

 

 

 

2.

ADD: TOTAL DEPOSITS NOT CREDITED

 

 

 

 

 

 

 

 

 

3.

SUBTRACT: OUTSTANDING CHECKS

 

 

 

 

 

 

 

 

 

4.

OTHER RECONCILING ITEMS

 

 

 

 

 

 

 

 

 

5.

MONTH END BALANCE PER BOOKS

 

$

0

 

$

0

 

$

0

 

$

0

 

6.

NUMBER OF LAST CHECK WRITTEN

 

 

 

 

 

 

 

 

 

 

INVESTMENT ACCOUNTS

 

 

 

DATE OF

 

TYPE OF

 

PURCHASE

 

CURRENT

 

BANK, ACCOUNT NAME & NUMBER

 

PURCHASE

 

INSTRUMENT

 

PRICE

 

VALUE

 

7.

 

 

 

 

 

 

 

 

 

 

8.

 

 

 

 

 

 

 

 

 

 

9.

 

 

 

 

 

 

 

 

 

 

10.

 

 

 

 

 

 

 

 

 

 

11.

TOTAL INVESTMENTS

 

 

 

 

 

$

0

 

$

0

 

 

CASH

 

12.

CURRENCY ON HAND

 

 

 

 

 

 

 

$

0

 

13.

TOTAL CASH – END OF MONTH

 

 

 

 

 

 

 

$

0

 

 



 

 

Monthly Operating Report

 

 

CASE NAME: Tri-Flow, Inc.

ACCRUAL BASIS-6

 

 

CASE NUMBER: 12-31553-bjh-11

 

 

MONTH: April 2012

 

PAYMENTS TO INSIDERS AND PROFESSIONALS

 

OF THE TOTAL DISBURSEMENTS SHOWN FOR THE MONTH, LIST THE AMOUNT PAID TO INSIDERS (AS DEFINED IN SECTION 101 (31) (A)-(F) OF THE U.S. BANKRUPTCY CODE) AND TO PROFESSIONALS. ALSO, FOR PAYMENTS TO INSIDERS, IDENTIFY THE TYPE OF COMPENSATION PAID (e.g. SALARY, BONUS, COMMISSIONS, INSURANCE, HOUSING ALLOWANCE, TRAVEL, CAR ALLOWANCE, ETC.). ATTACH ADDITIONAL SHEETS IF NECESSARY.

 

INSIDERS

 

 

 

TYPE OF

 

AMOUNT

 

TOTAL PAID

 

NAME

 

PAYMENT

 

PAID

 

TO DATE

 

1.

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

6.

TOTAL PAYMENTS TO INSIDERS

 

 

 

$

0

 

$

0

 

 

PROFESSIONALS

 

 

 

 

DATE OF COURT

 

 

 

 

 

 

 

TOTAL

 

 

 

 

ORDER AUTHORIZING

 

AMOUNT

 

AMOUNT

 

TOTAL PAID

 

INCURRED

 

NAME

 

PAYMENT

 

APPROVED

 

PAID

 

TO DATE

 

& UNPAID *

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

 

 

 

6.

TOTAL PAYMENTS TO PROFESSIONALS

 

$

0

 

$

0

 

$

0

 

$

0

 

 


*                 INCLUDE ALL FEES INCURRED, BOTH APPROVED AND UNAPPROVED

 

POSTPETITION STATUS OF SECURED NOTES, LEASES PAYABLE AND ADEQUATE PROTECTION PAYMENTS

 

 

 

 

SCHEDULED

 

AMOUNTS

 

 

 

 

 

 

MONTHLY

 

PAID

 

TOTAL

 

 

 

 

PAYMENTS

 

DURING

 

UNPAID

 

NAME OF CREDITOR

 

DUE

 

MONTH

 

POSTPETITION

 

1.

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

6.

TOTAL

 

$

0

 

$

0

 

$

0

 

 



 

 

Monthly Operating Report

 

 

CASE NAME: Tri-Flow, Inc.

ACCRUAL BASIS-7

 

 

CASE NUMBER: 12-31553-bjh-11

 

 

 

MONTH:   

April 2012

 

QUESTIONNAIRE

 

 

 

YES

 

NO

1.

HAVE ANY ASSETS BEEN SOLD OR TRANSFERRED OUTSIDE THE NORMAL COURSE OF BUSINESS THIS REPORTING PERIOD?

 

 

X

2.

HAVE ANY FUNDS BEEN DISBURSED FROM ANY ACCOUNT OTHER THAN A DEBTOR IN POSSESSION ACCOUNT?

 

 

X

3.

ARE ANY POSTPETITION RECEIVABLES (ACCOUNTS, NOTES, OR LOANS) DUE FROM RELATED PARTIES?

 

 

X

4.

HAVE ANY PAYMENTS BEEN MADE ON PREPETITION LIABILITIES THIS REPORTING PERIOD?

 

 

X

5.

HAVE ANY POSTPETITION LOANS BEEN RECEIVED BY THE DEBTOR FROM ANY PARTY?

 

 

X

6.

ARE ANY POSTPETITION PAYROLL TAXES PAST DUE?

 

 

X

7.

ARE ANY POSTPETITION STATE OR FEDERAL INCOME TAXES PAST DUE?

 

 

X

8.

ARE ANY POSTPETITION REAL ESTATE TAXES PAST DUE?

 

 

X

9.

ARE ANY OTHER POSTPETITION TAXES PAST DUE?

 

 

X

10.

ARE ANY AMOUNTS OWED TO POSTPETITION CREDITORS DELINQUENT?

 

 

X

11.

HAVE ANY PREPETITION TAXES BEEN PAID DURING THE REPORTING PERIOD?

 

 

X

12.

ARE ANY WAGE PAYMENTS PAST DUE?

 

 

X

 

IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS “YES,” PROVIDE A DETAILED EXPLANATION OF EACH ITEM. ATTACH ADDITIONAL SHEETS IF NECESSARY.

 

 

INSURANCE

 

 

 

YES

 

NO

1.

ARE WORKER’S COMPENSATION, GENERAL LIABILITY AND OTHER NECESSARY INSURANCE COVERAGES IN EFFECT?

 

 

X

2.

ARE ALL PREMIUM PAYMENTS PAID CURRENT?

 

 

X

3.

PLEASE ITEMIZE POLICIES BELOW.

 

 

 

 

IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS “NO,” OR IF ANY POLICIES HAVE BEEN CANCELLED OR NOT RENEWED DURING THIS REPORTING PERIOD, PROVIDE AN EXPLANATION BELOW. ATTACH ADDITIONAL SHEETS IF NECESSARY.

This is a shell company with no assets, liabilities, operations, or employees

 

 

INSTALLMENT PAYMENTS

 

TYPE OF

 

 

 

 

 

PAYMENT AMOUNT

POLICY

 

CARRIER

 

PERIOD COVERED

 

& FREQUENCY