Joint Application For Sale And Transfer Of Permanent Authority To Transport Passenger Or Household Goods {707}

State Form 50219 (R5 / 3-16) Form 707 Indiana ID/USDOT Number _________________________ (To be completed by the department) Joint Application for Sale and Transfer of Permanent Authority To Transport Passenger or Household Goods Joint application for sale and transfer of ___________________ by the Indiana Department of Revenue. (Certificate or Permit Number) 1. Purchaser Information a. Purchaser's Name (include DBA, if applicable)________________________________________________________ ________________________________________________________________________________________ b. Street Address ____________________________________________________________________________ c. City, State, Zip Code _______________________________________________________________________ d. Telephone Number _____________ County ________________ Email Address ________________________ e. Principal place of business in Indiana (if other than above): ________________________________________________________________________________________ (Street Address) (City) (State) (Zip Code) _______________________________________ (County) f. Check One: Partnership ____ Corporation _____ Individual ____ Other ____ g. If purchaser is a partnership, give the name and address of each member thereof; if purchaser is a corporation, give the name, title, and address of each principal officer. Name __________________________ Address _________________________________________________ Name __________________________ Address _________________________________________________ Name __________________________ Address _________________________________________________ h. If purchaser is a corporation, LP or LLC, provide the State and the date of incorporation. ________________________________________________________________________________________ (State) (Date of Incorporation) (Total Number of Shares Outstanding) Last year annual report was filed with Indiana Secretary of State __________________________ American LegalNet, Inc. www.FormsWorkFlow.com i. List the name of each shareholder and the number of shares held by each shareholder: Name Number of Shares j. List all other motor carrier companies which hold Indiana Intrastate Authority in which each shareholder has an interest. Provide the Indiana intrastate certificate or permit numbers held by these companies. Motor Carrier Company Certificate or Permit Number k. If currently operating under an Indiana certificate or permit, provide the number: Certificate Number __________________________ Permit Number _________________________________ 2. Seller Information a. Seller's Name (include DBA, if applicable) ___________________________________________________________ ________________________________________________________________________________________ b. Street Address ____________________________________________________________________________ c. City, State, Zip Code _______________________________________________________________________ d. Telephone Number _____________________________ County _____________________________________ e. Principal place of business in Indiana (if other than above): f. Check One: Partnership _____ Corporation _____ Individual _____ Other _____ g. If seller is a partnership, give the name and address of each member thereof; if seller is a corporation, give the name, title, and address of each principal officer: Name __________________________ Address _________________________________________________ Name __________________________ Address _________________________________________________ Name __________________________ Address _________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com h. If seller is a corporation, provide the State and the date of incorporation. ________________________________________________________________________________________ (State) (Date of Incorporation) Last year annual report was filed with Indiana Secretary of State: ____________________________________ i. List all Indiana intrastate authority certificate or permit numbers which the seller will be retaining. (Attach Copies) ______________________________________________________________________________________________________________ j. Is the seller currently in bankruptcy? Yes No If yes, indicate cause number, date of filing and in what court filed:____________________________________ ________________________________________________________________________________________ k. Has any shareholder, partner or owner of seller ever been a shareholder, partner or owner of a motor carrier which has filed bankruptcy? Yes No If yes, complete the following: Motor Carrier Date of Bankruptcy Petition Cause Number of Bankruptcy Petition Court Filed In Name of Shareholder, Partner or Owner Did this motor carrier hold Indiana intrastate authority? Yes No If yes, what happened to the certifi- cate or permit as a result of the bankruptcy? _____________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ l. Has the seller performed continuous and adequate service under the certificate or permit now pending sale and transfer? _________________________________________________________________________________ In support of this application, the purchaser submits the following exhibits, attached hereto and made part hereof: Exhibit A Exhibit B A statement describing purchaser's financial status, including a brief statement of assets and liabilities as of the date of application, and a copy of applicant's most recent balance sheet and income statement. A certificate from the Secretary of State of Indiana showing purchaser is registered to do business in Indiana (if the purchaser is a non-resident corporation); or A certificate of existence from the Secretary of State of Indiana (if the purchaser is an Indiana (corporation). A copy of the certificate or permit being transferred including the scope of authority granted by the Department. If seller is currently in bankruptcy, a copy of the bankruptcy petition. Exhibit C Exhibit D - American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, the joint applicants ask that the Indiana Department of Revenue approve the sale and transfer of ____________________ number ____________________ and issue a ______________________ to the purchaser (Certificate o