Year-End Financial Balance Sheet

YEAR-END FINANCIAL BALANCE SHEET

Company Name:

Company Address:

Fiscal Year End Date:   Accounting Method: Accrual Cash Other

ASSETS

Current Assets Current Year / Prior Year

Cash and cash equivalents:

Accounts receivable, net:

Inventory:

Prepaid expenses and other current assets:

Total Current Assets:

NONCURRENT ASSETS

Property, plant and equipment, gross:

Accumulated depreciation:

Goodwill and intangible assets, net:

Other long-term assets:

Total Noncurrent Assets:

Total Assets:

LIABILITIES

Current Liabilities Current Year / Prior Year

Accounts payable:

Short-term borrowings:

Accrued liabilities:

Total Current Liabilities:

LONG-TERM LIABILITIES

Long-term debt:

Deferred tax liabilities and other:

Total Liabilities:

SHAREHOLDERS' EQUITY

Common stock, par value:

Additional paid-in capital:

Retained earnings:

Total Shareholders' Equity:

Total Liabilities and Shareholders' Equity:

NOTES AND FOOTNOTES

CERTIFICATION

The undersigned certifies, to the best of their knowledge and belief, that the accompanying balance sheet presents fairly, in all material respects, the financial position of the Company as of the fiscal year end shown above. The statements have been prepared in accordance with the selected accounting method and include all material liabilities, commitments and contingencies required to be disclosed by applicable accounting standards and governing law.

Auditor/Preparer Independence Declaration: Preparer affirms independence with respect to the period presented. Independence waived/explained in footnotes.

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