BUSINESS FINANCIAL STATEMENT - NV Contractors Board

BUSINESS FINANCIAL STATEMENT

If you need assistance in completing this form, you are encouraged to seek the advice of an accountant.

Applicant / Licensee Name:___________________________________________________________________________

Business financial statement of _________________________________________________________ ___________

(Name)

(State Organized)

Business Entity: Sole Proprietorship

Corporation

Limited Liability Company

Limited Partnership

General Partnership

_______________________________________________________________________________________________

Street Address

City

State

Zip

Phone Number

CURREN T ASSETS Cash ? on hand....................................................... Cash ? in banks (schedule 1)............................... Securities - stocks / bonds (schedule 2)..........

Accounts receivable (schedule 3)........................

Current notes receivable (schedule 4)............. Other current assets (schedule 5).....................

As Of ___________________________

Month / Date / Year

Dollars

CURREN T LI ABI LI TI ES Accounts payable (schedule 3)..........................

$0.00 $0.00 $0.00 $0.00

Taxes payable........................................................ Other current liabilities (schedule 5)................

Current portion notes payable..................... (portion of notes payable due within the next 12 months)

$0.00

Dollars $0.00

$0.00

Tot a l Cur r e nt Asse t s

FI XED ASSETS Real estate (schedule 6) Vehicles & equipment (schedule 7)................... Long term notes receivable (attach schedule) Other assets and investments (schedule 8)....

$0.00

Tot a l Cu r r e n t Lia bilit ie s

Dollars

LON G TERM LI ABI LI TI ES

$0.00 Real estate debt (schedule 6)...........................

$0.00 Other long-term debt (schedule 8)...............

Long term notes payable (schedule 9)..........

$0.00

$0.00 Dollars

$0.00

Total Fixed Assets TOTAL ASSETS

$0.00 $0.00

Total Long Term Liabilit ies TOTAL LI ABI LI TI ES EQUI TY

$0.00 $0.00 $0.00

Equity is total assets minus total liabilities Working capital is total current assets minus total current liabilities

Net Sales: Net Profit: Con t in ge n t Lia bilit ie s:

Nevada State Contractors Board Business Financial Statement Form Page 1 of 4

(Rev 12/05)

SUPPLEM EN TARY SCH ED ULES ( Note: I f space is insufficient, attach separate sheet with additional inform ation)

SCHEDULE 1 BANK ACCOUNTS

Name and address of bank(s)

Current balance

SCHEDULE 2 SECURITIES - STOCKS AND BONDS

Name of Security

TOTAL:

$0.00 Value

Accounts Receivable

TOTAL:

SCHEDULE 3 ACCOUNTS RECEIVABLE / ACCOUNTS PAYABLE

Amount

Accounts Payable

$0.00 Amount

TOTAL:

$0.00

Nevada State Contractors Board Business Financial Statement Form Page 2 of 4

TOTAL:

$0.00

(Rev 12/05)

SCHEDULE 4 NOTES RECEIVABLE

Name and Address of Debtor

Due Date

Amount

TOTAL:

SCHEDULE 5 OTHER CURRENT ASSETS / OTHER CURRENT LIABILITIES

Other Current Assets (Itemize)

Value

Other Current Liabilities (Itemize)

$0.00

Amount

Location / Description

TOTAL:

$0.00

SCHEDULE 6 REAL ESTATE

Mortgage or Lien Holder

Cost

TOTAL:

$0.00

Current

Amount

Market Value Encumbered

Monthly Payments

Description

TOTAL:

$0.00

$0.00

$0.00

$0.00

SCHEDULE 7 VEHICLES & EQUIPMENT

Year Manufactured

Book Value

Nevada State Contractors Board Business Financial Statement Form Page 3 of 4

TOTAL:

$0.00 (Rev 12/05)

SCHEDULE 8 OTHER ASSETS AND INVESTMENTS / OTHER LONG TERM DEBT

Other assets and investments (Itemize)

Value

Other long-term debt (Itemize)

Amount

TOTAL:

$0.00

SCHEDULE 9 NOTES PAYABLE

Name and Address To Whom Due* *

TOTAL:

$0.00

Maturity Date

Monthly Payment

Amount Owed

TOTAL:

$0.00

$0.00

* * I f you have list ed a note payable to a stockholder, is that stockholder w illing to subordinate the not e payable to all other creditors?

Yes - include a signed and notarized stipulation agreement stating that all sub contractors, suppliers and other creditors would be compensated prior to the stockholders receiving funds.

No

The information contained in this statement is for the purpose of establishing financial responsibility, in accordance with NRS 624.262, NRS 624.263 and NRS 624.264. I have carefully read and submitted the foregoing information provided on all the pages of this statement.

I hereby certify, under penalty of perjury that the information is presented as a true, accurate and complete statement of our financial condition on the date indicated.

Signature of Principal or Ow ner

Print Nam e

Date Signed

Pr iva cy N ot ice : Pursuant t o NR S 624. 110(2)-Except as otherwise re quired in NRS 6 24.327, c redit re ports, re ferences, financ ial information and data pertaining to a licensee's net worth are confidential and not open to public inspection.

Nevada State Contractors Board Business Financial Statement Form Page 4 of 4

(Rev 12/05)

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