(please print, fill out and fax to coleman-pension.com at (516) 627-1502)

 

 

_______________________________________   Year Ending    ____/___/___

  

 

                                         Market Value    Market Value

                                         Beginning of    End of

A. ASSETS                                Plan Year       Plan Year

 

  1. Cash, Bank Accounts,

     Savings Certificates               $___________    $___________

   

  2. Stock and Corporate Bonds           ___________     ___________

 

  3. Government Securities               ___________     ___________

 

  4. Mutual Funds                        ___________     ___________

 

  5. Loans                               ___________     ___________

 

  6. Contributions Receivable            ___________     ___________

 

  7. Other (please specify)              ___________     ___________

 

     TOTAL ASSETS

     add 1 through 8                    $===========    $===========

 

B.  LIABILITIES

 

  1. Policy Loans                       $___________    $___________

 

  2. Payables                            ___________     ___________

 

  3. Other Liabilities                   ___________     ___________

 

     TOTAL LIABILITIES

        (1+2+3)                         $===========    $===========

 

C. NET ASSETS (Total Assets

   minus Total Liabilities)             $===========    $===========

 

 

____________________________             ____________                          

Trustee                                  Date Signed