Financial Statement - Business



Financial Information Statement for Businesses(if you need additional space, please attach a separate sheet)92075000complete all blocks, except shaded areas. Write “N/A” (not applicable) in those blocks that do not applySection 1- Personal informationBusiness Name FORMTEXT ?????Business Phone FORMTEXT ????? Registration Number (UBI) FORMTEXT ?????Physical Address (street, city, state and county) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Mailing Address (if different) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Does the business engage in Internet Sales FORMCHECKBOX Yes FORMCHECKBOX NoEmployer Identification (EIN) FORMTEXT ?????Business Website FORMTEXT ?????List Affiliated Businesses (include UBI) FORMTEXT ????? FORMTEXT ?????Type of Business (describe) FORMTEXT ?????Tax Year of last filed Federal Income Tax Return FORMTEXT ?????Form Number FORMTEXT ?????Net Income FORMTEXT ?????Number of Employees FORMTEXT ?????Section 2- Business Personnel and contactsPartners, Officers, LLC Members, Major Shareholders, Etc.Full Name FORMTEXT ?????Title FORMTEXT ?????Home Address FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SSN FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Email: FORMTEXT ?????Home Phone FORMTEXT ?????Cell Phone FORMTEXT ?????Effective Date FORMTEXT ?????Total Shares/Interest FORMTEXT ?????Full Name FORMTEXT ?????Title FORMTEXT ?????Home Address FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SSN FORMTEXT ?????Email: FORMTEXT ?????Home Phone FORMTEXT ?????Cell Phone FORMTEXT ?????Effective Date FORMTEXT ?????Total Shares/Interest FORMTEXT ?????Full Name FORMTEXT ????? Title FORMTEXT ?????Home Address FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SSN FORMTEXT ?????Email: FORMTEXT ?????Home Phone FORMTEXT ?????Cell Phone FORMTEXT ?????Effective Date FORMTEXT ?????Total Shares/Interest FORMTEXT ?????Payment ProcessorPayment Processor (First Data, PayPal, , Google Checkout, etc.)AddressPayment Processor Account Number FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Credit Cards Accepted by the BusinessCredit CardMerchant Account NumberMerchant Account Provider, Name & Address FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Section 3- Financial informationIs the business party to a lawsuit (If yes, answer the following) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Plaintiff FORMCHECKBOX DefendantAmount of Suit FORMTEXT ?????Subject of Suit FORMTEXT ?????Possible Completion Date FORMTEXT ?????Has the business ever filed bankruptcy (If yes, answer the following) FORMCHECKBOX Yes FORMCHECKBOX NoDate Filed/Filing Anticipated FORMTEXT ?????Discharge/Closure Date FORMTEXT ?????Bankruptcy Filing Number FORMTEXT ?????Type filed FORMTEXT ?????Any increase/decrease in income anticipated (If yes, answer the following) FORMCHECKBOX Yes FORMCHECKBOX NoExplain (use attachment if needed) FORMTEXT ?????How much will it increase/decrease?$ FORMTEXT ?????When will it increase/decrease? FORMTEXT ?????Is the individual or sole proprietorship a beneficiary of a trust, estate, or life insurance policy FORMCHECKBOX Yes FORMCHECKBOX No(If yes, answer the following) Name of the trust, estate, or policyAnticipated amount to be received FORMTEXT ?????When will the amount be received FORMTEXT ?????In the past 3 years have any assets been transferred by the individual for less than full value FORMCHECKBOX Yes FORMCHECKBOX NoList Asset FORMTEXT ?????Value at time of transfer FORMTEXT ?????Date Transferred FORMTEXT ?????To whom or where it transferred FORMTEXT ?????Section 4- business asset and liability informationBusiness Bank accounts (checking, online banking, money market accounts, savings, etc.)Type of AccountName and Address of Financial InstitutionAccount NumberBalance FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Amount of Cash on Hand FORMTEXT ?????Available Credit (Bank credit cards, Credit Unions, Savings & Loans, Lines of Credit) Attach additional sheets if neededType of Account or CardName and Address of Credit InstitutionCredit LimitAmount OwedCredit Available FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Accounts/Notes receivable (Include all current contract jobs, loans to Family Members, loans to partners, etc.)You may attach Aged Receivable Report (Customer Balance Summary Report)NameAddress & PhoneAmount DueDue DateDays Past Due FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Do you currently factor receivables or use them as collateral for loans? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete the followingName of factor or lender FORMTEXT ?????Address FORMTEXT ?????Phone FORMTEXT ?????If any of your company’s accounts or notes receivables are involved in bankruptcy or other court proceedings, please explain. FORMTEXT ?????Investments (stocks, bonds, mutual funds, stock options, and Certificates of Deposit, government securities)Name and Address of CompanyUsed as collateral on loanCurrent ValueLoan BalanceEquity(value minus loan) FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Real Property (include all real property and land the business owns/leases/rents Attach additional sheets if neededProperty DescriptionPurchase/Lease DateCurrent Fair Market ValueCurrent Loan BalanceMonthly Payment AmountDate of Final PaymentEquity(Fair Market Value Minus Loan) FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMCHECKBOX Purchased FORMCHECKBOX LeasedLocation (Street, City, State, Zip & County) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Lender/Lessor/Landlord Name, Address & Phone FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Asset registered to: FORMTEXT ?????Property DescriptionPurchase/Lease DateCurrent Fair Market ValueCurrent Loan BalanceMonthly Payment AmountDate of Final PaymentEquity(Fair Market Value Minus Loan) FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMCHECKBOX Purchased FORMCHECKBOX LeasedLocation (Street, City, State, Zip & County) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Lender/Lessor/Landlord Name, Address & Phone FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Asset registered to: FORMTEXT ?????Vehicles Leased & Purchased Include boats, RVs, motorcycles , and airplanes Attach additional sheets if neededDescription FORMTEXT ?????Purchase/Lease DateCurrent Fair Market ValueCurrent Loan BalanceMonthly Payment AmountDate of Final PaymentEquity(Fair Market Value Minus Loan) FORMCHECKBOX Purchased FORMCHECKBOX Leased FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Year FORMTEXT ?????Mileage FORMTEXT ?????License # FORMTEXT ?????Lender/Lessor Address & Phone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Make FORMTEXT ?????Model FORMTEXT ?????Asset registered to: FORMTEXT ?????Description FORMTEXT ?????Purchase/Lease DateCurrent Fair Market ValueCurrent Loan BalanceMonthly Payment AmountDate of Final PaymentEquity(Fair Market Value Minus Loan) FORMCHECKBOX Purchased FORMCHECKBOX Leased FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Year FORMTEXT ?????Mileage FORMTEXT ?????License # FORMTEXT ?????Lender/Lessor Address & Phone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Make FORMTEXT ?????Model FORMTEXT ?????Asset registered to: FORMTEXT ?????Business Equipment Include all machinery, equipment, merchandise, inventory, and/or other assets Attach additional sheets if neededAsset Description FORMTEXT ?????Purchase/Lease DateCurrent Fair Market ValueCurrent Loan BalanceMonthly Payment AmountDate of Final PaymentEquity(Fair Market Value Minus Loan) FORMCHECKBOX Purchased FORMCHECKBOX Leased FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Location (Street, City, State, Zip & County) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Lender/Lessor/Landlord Name, Address & Phone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Asset DescriptionPurchase/Lease DateCurrent Fair Market ValueCurrent Loan BalanceMonthly Payment AmountDate of Final PaymentEquity(Fair Market Value Minus Loan) FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Location (Street, City, State, Zip & County) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Lender/Lessor/Landlord Name, Address & Phone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Asset DescriptionPurchase/Lease DateCurrent Fair Market ValueCurrent Loan BalanceMonthly Payment AmountDate of Final PaymentEquity(Fair Market Value Minus Loan) FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Location (Street, City, State, Zip & County) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Lender/Lessor/Landlord Name, Address & Phone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Additional information concerning financial condition (Court proceedings, transfer of assets in last 3 years, changes in market conditions, etc). Include information regarding company participation in trust estates, profit sharing plans, etc. Attach additional sheets if needed FORMTEXT ?????Tax LiabilitiesDate lien was filed or assessedCurrent Amount OwedMonthly Payment AmountDate first payment was madeName & Address of Lien/Note HolderIRS FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Labor & Industries FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Employment Security FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other Taxes Owed (specify) FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other Business LiabilitiesDescriptionSecured/unsecuredDate PledgedBalance OwedDate of Final PaymentPayment Amount FORMTEXT ????? FORMCHECKBOX Secured FORMCHECKBOX Unsecured FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????NameAddressPhone FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DescriptionSecured/unsecuredDate PledgedBalance OwedDate of Final PaymentPayment Amount FORMTEXT ????? FORMCHECKBOX Secured FORMCHECKBOX Unsecured FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????NameAddressPhone FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SECTION 5- Business Income and Expense Information You may attach Profit & Loss Report or Income Statement along with this sectionThe following information is based monthly business income and expensesAccounting Method Used: FORMCHECKBOX Accrual FORMCHECKBOX Cash(must be same as with IRS)Total Business IncomeTotal Business ExpensesSourceGross MonthlyExpense ItemsActual MonthlyGross Receipts$ FORMTEXT ?????Materials Purchased$ FORMTEXT ?????Gross Rental Income$ FORMTEXT ?????Inventory Purchased$ FORMTEXT ?????Interest$ FORMTEXT ?????Gross Wages & Salaries$ FORMTEXT ?????Dividends$ FORMTEXT ?????Rent$ FORMTEXT ?????Cash$ FORMTEXT ?????Supplies$ FORMTEXT ?????Other Income (specify below)$ FORMTEXT ?????Utilities/Telephone$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Vehicle Gasoline/Oil$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Repairs & Maintenance$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Insurance$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Current Taxes$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Notes or Loan Payments $ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Other (specify)$ FORMTEXT ?????Total Income$ FORMTEXT ?????Total Expenses$ FORMTEXT ?????Net Income (Income – Expenses)$ FORMTEXT ?????SECTION 6Please include the following checked documents with your financial statement: FORMCHECKBOX Copies of the last three month’s bank statements for the business FORMCHECKBOX Copies of the most recent business financial statements (including but not limited to balance sheets and profit/loss statements) should be submitted with this form. FORMCHECKBOX Attach a copy of all currently recorded UCC-1 financing statements on which the business is either a creditor or a debtor FORMCHECKBOX Each owner, partner or officer must disclose their name, address and the nature of any involvement or interest in other businesses. FORMCHECKBOX FORMTEXT OtherAdditional Comments and proposal for Electronic Partial Payment AgreementI am requesting to pay the total liability plus accrued penalties and interest in the following manner:$ FORMTEXT ?????To be paid (select one) FORMCHECKBOX Monthly FORMCHECKBOX Twice a Month FORMCHECKBOX Weekly Comments: FORMTEXT ?????If your payment terms are accepted, the payment amount you proposed will be withdrawn from your bank account electronically. Penalty and interest will accrue, as provided by law, until the balance is paid in full.Certification I declare that to the best of my knowledge and belief this statement of assets, liabilities, and other information is true, correct, and complete and I hereby authorize the Department of Revenue to verify the information contained herein as they deem necessary. FORMTEXT ????? FORMTEXT ?????Signature of Authorized Corporate Officer FORMTEXT TitlePrint Name of Authorized Corporate OfficerDate FORMTEXT ????? FORMTEXT ?????Signature of Authorized Corporate Officer FORMTEXT TitlePrint Name of Authorized Corporate OfficerDate ................
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