Business Assets Questionnaire

BUSINESS ASSETS QUESTIONNAIRE

RECITALS

WHEREAS, Requesting Entity: is seeking a comprehensive statement of assets and related information from the Respondent for the purpose of evaluation, recordkeeping, and transaction diligence;

WHEREAS, Respondent (Business Name): agrees to provide complete and accurate information regarding all material assets owned, leased, licensed or otherwise controlled by the business as of the Effective Date specified below;

WHEREAS, the information supplied will be relied upon by the Requesting Entity and its authorized representatives for purposes described above and must be certified by an authorized officer of the Respondent.

INSTRUCTIONS

Complete every applicable section. If a section does not apply, enter "N/A". Provide supporting documentation where requested and list any attachments in the Supporting Documentation section. All monetary amounts should be expressed in the business's reporting currency and rounded to two decimals.

BUSINESS IDENTIFICATION

ASSET INVENTORY — TANGIBLE PERSONAL PROPERTY

Provide descriptions for major items. Attach additional sheets if necessary. For each listed asset, supply purchase documentation, title (if any), and warranties where applicable.

Serial Number:   Acquisition Date:   Acquisition Cost:   Current Book Value:

Location:   Condition:

Serial Number:   Acquisition Date:   Acquisition Cost:   Current Book Value:

Location:   Condition:

Serial Number:   Acquisition Date:   Acquisition Cost:   Current Book Value:

Location:   Condition:

INTANGIBLE ASSETS

Indicate existence and provide registration or reference numbers, estimated values and supporting documentation.

FINANCIAL ASSETS

List bank and investment accounts that the business controls. Provide current balances and account identifiers.

Account Type:   Account No.:   Current Balance:

Account Type:   Account No.:   Current Balance:

REAL PROPERTY, LEASES & ENCUMBRANCES

Identify owned real property, properties under lease, and any recorded liens or encumbrances against tangible or intangible assets.

INSURANCE

Provide material insurance policies covering assets, including policy limits and expiration dates.

Policy Number:   Coverage Type:   Policy Limit:

MATERIAL CONTRACTS & OBLIGATIONS

List all material contracts (supply agreements, customer contracts, loan agreements) that create obligations or rights affecting business assets.

SUPPORTING DOCUMENTATION

List documents attached to this questionnaire that substantiate the assets reported (e.g., titles, invoices, appraisals, registration certificates, insurance policies).

CONFIDENTIALITY

All information provided in this questionnaire is to be treated as confidential by the Requesting Entity and its representatives. The Requesting Entity may use disclosed information only for the purposes described in the Recitals and shall not disclose such information to third parties except as required by law or as agreed in writing by the Respondent.

GOVERNING LAW

This questionnaire, the information provided herein, and any disputes arising out of the submission of this information shall be governed by and construed in accordance with the laws of the state identified below without regard to conflict of law principles.

ENTIRE AGREEMENT & CERTIFICATION

This questionnaire, together with any attachments and certifications executed in connection herewith, constitutes the entire written statement of assets supplied by the Respondent to the Requesting Entity for the purposes stated herein. No oral statements or representations shall be deemed part of this submission.

CERTIFICATION: I, the undersigned, certify under penalty of perjury that the information contained in this Business Assets Questionnaire and any attached documents is true, complete and accurate to the best of my knowledge and belief, and that I am authorized to make this certification on behalf of the Respondent.

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