Hill Commercial Purchase Statement

Please fill in all the blanks to enable us to more effectively respond to all of your answers. When you are finished, click the Submit button to send the information to us. Note: The fields marked with and asterisk (*) are required.

NOTE: You should also e-mail or fax any additional year-end financial statements for the past two years and current prior month-end financial statements. Financial statements should include balance sheet, profit and loss statement, and statement of cash flows. E-mail them to info@hillfreightliner.com or fax to (574) 262-3443. 

*Purchaser:
*Address:
*City:
*State: *ZIP:
*E-mail:
*ICC #:
*SS #:
*Fed. ID #:

Business Information:
C Corp.
S Corp		 *Years In Business:

Office/Key Managers:
*A minimum of one row must be completed for the form to submit.
Name: Title: SS #: Stock %
Ownership 		Years
w/ Co.		 Years
Exp.

Customers/Contracts:
Name: Phone: $ Revenue
Year		 % Total Rev.

Equipment:
  # Financed # Leased
(Capital) 		# Leased
(Operating) 		# Owned
(F&C) 		Total
Units:
Power Units:
Trailers:

(Provide equipment listing if available.)

Number Of Owner Operators Utilized:

Financial Information:
*Insurance Co. Phone #
*Physical Damage Deductible *Liability Limits

Bank References:
*A minimum of one row must be completed for the form to submit.
Name: Contact: Phone: City: State: Acct. #:

Equipment Financing & Leasing References:
(This information should correspond with the information contained in the attached financial statements. Include paid out creditors if this information is available.)
Name: Contact: Phone: City: State: Acct. #:

Legal Actions:
*Prior Bankruptcy: Yes No     *Tax Liens:  Yes No
*Lawsuits Pending: Yes No    *Judgments: Yes No


Signature:
For the purposes of procuring and maintaining credit, the undersigned submits the foregoing statement and information, including any supplemental sheets, as being a full, true, and correct statement of my/our financial condition on the date stated.

Please e-mail or fax any additional year-end financial statements for the past two years and current prior month-end financial statements. Financial statements should include balance sheet, profit and loss statement, and statement of cash flows. E-mail them to info@hillfreightliner.com or fax to (574) 262-3443.

By electronically signing your name (typing) you are agreeing to let Hill Truck Sales utilize all necessary tools to check your credit standing. This includes doing a credit check and report.

*Signature:
*Date: