Utah State Tax Commission
                                  210 North 1950 West - Salt Lake City - Utah 84134 - Telephone (801) 297-2200                           TC-803
                                                                                                                                         Rev. 1/96
                                  Collection Information For Businesses

1.  Name and Address of Business                                 2.  Business Telephone Number

                                                                 3. (Check appropriate box)
                                                                               Sole Proprietor                   Other (specify)
                                                                               Partnership
                                                                               Corporation
4. Name and Title of Person Interviewed                          5. Account Number:                              6. Type of Business
                                                                 Sales
                                                                 Withholding
                                                                 Other

7. Information about Owner, Partners, Officers, etc.

Name and Title                    EffectiveDate          Home Address          TelephoneNumber                 SocialNumberSecurity Total Shares

Section One: General Financial Information
8. Latest Filed Income Tax Return                   Form    Tax Year Ended                                     Net Income Before Taxes

Bank Accounts (List all types of accounts including payroll and general, savings, certificates of deposit, etc.)

Name of Institution                                      Address               Type ofAccount                    AccountNumber           Balance
                                                                                                                                   $

                                                                               9. Total (Enter in item 16)

Bank Credit Available (Lines of credit, etc.)

                                                                               Credit                          Amount          Credit     Monthly
Name of Institution                                 Address                    Limit                             Owed          Available  Payment
                                                                             $                                 $      $                  $

                    10. Totals (Enter in Items 23 or 24 as appropriate)

                                                                                                                                      FORM TC803A 1/96

SECTION I, General Financial Information - Continued
11.  Real Estate: (Enter values, balance due, equity in asset, and monthly payment in item 19.)

  Brief Description and Type of Ownership                                   Address (Include County and State)
a.

b.

c.

12. Life Insurance Policies Owned with Business as Beneficiary
                                                                                                                                 Accumulative
  Name Insured Company                                              Policy Number Type         Face Amount                       Cash Value
                                                                                        $                                       $

                                                                                  12. Total (Enter in Item 18)
13. Additional Information Regarding Financial Condition (court proceedings, bankruptcies filed or anticipated, transfers of
assets for less than full value, changes in market conditions, etc.; including information regarding company participation
in trusts, estates, profit-sharing plans, etc.)

14.  Accounts/Notes Receivable (Include loans to stockholders, officers, partners, etc.)

  Name                                              Address                  Amount Due                                Date Due  Status

                                                                            $

                                               14, Total (Enter in Item 17) $
For additional information, you may access the Tax Commission's World Wide Home Page at: http://www.tax.ex.state.ut.us           FORM TC803B 1/96
If you need an accommodation under the Americans with Disabilities Act, contact the Tax Commission at (801) 297-3811 or Telecommunication Device for the
Deaf (801) 297-3819. Please allow three working days for a response.

Section Two: Asset and Liability Analysis

         Description                     MarketCurrentLiabilitiesBalance  Equityin AmountMonthlyofName and Address of      Date    DateFinalof
                                         Value          Due               Asset     Payment       Lien/Note Holder/Obligee Pledged Payment
              (a)                          (b)          (c)               (d)       (e)                (f)                 (g)     (h)
15. Cash                                                                 $
16. Bank Accounts (from item 9)

17. (fromAccounts/Notesitem 14)Receivable
18. (fromLife Insuranceitem 12)Loan Value
              a                          $            $                            $
19. Real      b
Property
              c
              d

20. Vehicles
Model, Year,
License

21. Machines
    and
Equipment
(Specify)

22. Merchan-
    dise
Inventory
(Specify)

23. Other
Assets
(Specify)
(from item
10)

24. Other
Liabili-
ties
(included
notes
and
judg-
ments)
(from
item 10)

25. Federal Taxes Owed
26. State Taxes Owed
27. Total

                                                                                                                           FORM TC803C 1/96

Section Three: Monthly Income and Expense Analysis
The following information applies to income and expenses          Accounting method used:  (cash or accrual)
during the period _________ to __________

                           Income                                                         Expenses

28. Gross receipts from sales, services, etc.            $        34. Materials purchased                   $

29. Gross rental income                                           35. Net wages and salaries

30. Interest                                                      36. Rent

31. Dividends                                                     37. Installment payments

32. Other income (specify)                                        38. Supplies

                                                                  39. Utilities/Telephone

                                                                  40. Gasoline/Oil

                                                                  41. Repairs and maintenance

                                                                  42. Insurance

                                                                  43. Current taxes

                                                                  44. Other (specify)

33. TOTAL                                                $        45. TOTAL                                 $

                                                                  46. NET DIFFERENCE                        $
CERTIFICATION

Under penalties of perjury, I declare that to the best of my knowledge and belief, this statement of assets,
liabilities, and other information is true, correct, and complete.

Signature:                                                                               Date:

                                                                                                             FORM TC803D 1/96