REPUBLICOFTHEPHILIPPINES

DepartmentofTransportationandCommunications

LANDTRANSPORTATIONFRANCHISINGANDREGULATORYBOARD
EastAvenue,QuezonCity

STATEMENTOFFINANCIALCAPABILITY
(ACTUALWORKINGCAPITAL)
ForIndividualOperator(Pleaseaccomplishbelow)

LASTNAME
FIRSTNAME
MIDDLENAME
DATEOFBIRTH

SEX

TINNO.

ForCorporation/Cooperative/Others(Pleaseaccomplishbelow)

NAMEOFCORPORATION/COOPERATIVE/OTHERS

SEC/CDAREGISTRATIONNO.

TINNO.

NAMEOFAUTHORIZEDREPRESENTATIVE

I.CURRENTASSETS
CASH
CashonHand
CashatBank(Savings/Current)
Others

AMOUNT/VALUE

PROPERTIES(CurrentorMarketValue)
RealEstate
Vehicles
Others
INVESTMENTS
CertificatesofDeposit(TimeDeposit,etc.)
Securities(Stocks,Bonds,MutualFunds,etc.)
BusinessInvestments(worthofshares,etc.)
InsurancePolicies(CashSurrenderValue)
Others
TOTALASSETS
II.CURRENTLIABILITIES
LOANSANDPAYABLES
CreditCardDebts
Loan/s(Housing,auto,etc)
Others

AMOUNT/VALUE

INVESTMENTDEBTS
Business/InsuranceDebts
Others
TOTALLIABILITIES

TOTALWORKINGCAPITAL(TotalAssetsTotalLiabilities)

NAME & SIGNATURE OF OPERATOR

SUBSCRIBED AND SWORN to before me this _______ day of __________ at ________________________________________________.

Affiant exhibited to me his _____________________ issued at _____________________ on ____________________________________.

Doc No.

: ________

Page No.

: ________

Book No.

: ________

Series of

: ________

NOTARY PUBLIC