Financial Physical Statement

FINANCIAL PHYSICAL STATEMENT

Prepared By:   Address:

Prepared For:   Address:

Effective Date:

RECITALS

WHEREAS, the Preparer has compiled a physical inventory and valuation of tangible assets, equipment and property in the possession or control of the Preparer as reflected in this Financial Physical Statement; and

WHEREAS, the Recipient requires an accurate, itemized and certified statement of such physical assets, including description, serial identification, date of acquisition, original cost, current fair market value, location and known encumbrances for purposes of financial review, collateral evaluation, or internal audit; and

WHEREAS, the parties agree that the representations and schedules contained herein will govern the parties' understanding of the physical assets noted and the reliance thereon by the Recipient, subject to the terms and conditions of this Statement.

SCOPE OF STATEMENT

The Preparer shall list and describe all tangible assets in the possession or control of the Preparer as of the Effective Date. The Statement shall include identification sufficient to permit physical inspection, stated original cost, current fair market value, location, and disclosure of any liens, security interests, leases, or other encumbrances affecting each item.

ASSET INVENTORY

Provide a complete, itemized inventory of physical assets. Include serial numbers or unique identifiers where applicable. If additional space is required, attach supplemental schedules and mark as Attachment A.

LIABILITIES AND ENCUMBRANCES

PAYMENT TERMS

The Recipient shall pay the Preparer for preparation, inspection and certification of the physical statement in accordance with the terms below. All fees are due in United States dollars unless otherwise specified.

Late payments shall accrue interest and fees as set forth below.

TERM AND TERMINATION

This Statement commences on the Start Date and, unless earlier terminated pursuant to this provision, continues until the End Date or until all deliverables have been provided and accepted.

Start Date:   End Date:

CONFIDENTIALITY

The parties acknowledge that information contained in or derived from this Statement may constitute Confidential Information. The Recipient shall hold such information in strict confidence and shall not disclose it to third parties except as required by law or with the prior written consent of the Preparer. Confidential Information shall not include information that is or becomes generally available to the public through no breach of this Statement.

GOVERNING LAW

This Statement shall be governed by and construed in accordance with the laws of the state indicated below, without regard to its conflicts of law principles. The parties consent to the exclusive jurisdiction of the federal and state courts located in that state for resolution of disputes.

ENTIRE AGREEMENT

This Statement, together with any attachments or supplemental schedules expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior and contemporaneous agreements, proposals, or representations, whether written or oral. No amendment shall be effective unless reduced to writing and signed by both parties.

CERTIFICATION

The undersigned certifies, under penalty of perjury, that the information contained in this Financial Physical Statement and any attachments is true, complete and accurate to the best of their knowledge and belief, and represents the physical condition and ownership/possession status of the assets listed as of the Effective Date.

Inventory Schedule Attached:   Photographic Evidence Attached:

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