Certified Statement of Lease

Certified Statement of Lease [49 CFR Section 376.11 (c)(2)]

______hereby certifies that the equipment described below is being operated by ______pursuant to a lease with the owner/lessor named below, as follows:

Make: ______

Year: ______

Model: ______

License #: ______State: ______

Owner: ______

VIN #: ______

Unit #: ______

Date of Lease: ______

Length of Lease: Until cancelled by either party or not less than 30 days’ written notice or until terminated pursuant to paragraph (b) on page 1.

There are not restrictions to the Lease relative to the commodities to be transported (with the exception of HazMat).

The original Lease is kept by ______at ______

______Date Exhibit “A”

Equipment List

Equipment # Year Make Model Serial # Lic. #

* To be completed by LESSOR and returned to ______to be included in Master Lease. List all units under Lease to ______. Exhibit “B”

This compensation agreement supersedes all existing compensation schedules, appendices, and addendum’s, and will be attached to all equipment leases. Effective ______and thereafter the rates, fees, and compensation schedule as outlined below will become the prevailing pay program.

All loads will be paid at $______/mile, $______/trip, $______/hr

______, by signature of the addendum, does hereby consent and agree to the terms and conditions stated above. Likewise the contractor and owner operator, by signature of this addendum, does here by consent and agree to the condition stated above.

______LESSOR

______Date Date Exhibit “C”

Receipt for Possession of Equipment

The undersigned hereby acknowledges possession of the equipment described in Exhibit “A,” Truck VIN # ______, Unit # ______at: ______received from ______this ______of ______, 200___ at ______o’clock am/pm.

______Exhibit “D”

Receipt of Return Equipment

The undersigned ______(LESSOR) hereby certified that he/her, as the duly qualified owner or agent of the owner or person authorized to have possession, has this ______day of ______, 200__ at ______o’clock am/pm, received from ______, the above described equipment.

Truck VIN #: ______

Unit #: ______

______Signature of Duly Authorized Date Representative of Owner or Person Entitled to Possession