BUSINESS FINANCIAL STATEMENT



PERSONAL INFORMATION NOTICEPursuant to the Federal Privacy Act (P.L. 93579) and the Information Practices Act of 1977 (Civil Code Sections 1798, et seq.), notice is hereby given for the request of personal information by this form. The requested personal information is voluntary. The principal purpose of the voluntary information is to facilitate the processing of this form. The failure to provide all or any part of the requested information may delay processing of this form. No disclosure of personal information will be made unless permissible under Article 6, Section 1798.24 of the IPA of 1977. Each individual has the right upon request and proper identification, to inspect all personal information in any record maintained on the individual by an identifying particular. Direct any inquiries on information maintenance to your IPA Office.PARTNERSHIP OR CORPORATIONFINANCIAL STATEMENT OFReceived at ___________________________________ BranchName _________________________________________________________Business _____________________________________________Address ______________________________________________________At Close of Business ____________________________ 20 ___TO:ASSETSDOLLARSCENTSLIABILITIESDOLLARSCENTSCash InNotes Payable to BanksCash on Hand (Name of Bank)Notes Payable and Trade Acceptances for MerchandiseNotes Receivable and Trade Acceptance (Includes $_____ Past DueNotes Payable to OthersAmounts Receivable$_____ Less Reserves$Accounts Payable (Includes $_____ Past Due) Customer’s (Includes $_____ Past Due)Due to Partners, Employees, Relatives, Officers, Stockholders or Allied CompaniesMerchandiseFinishedHow ValuedChattel Mortgages and Contracts Payable (Describe Monthly Payments) $MerchandiseUnfinishedHow ValuedFederal and State Income TaxMerchandiseRaw MaterialHow ValuedAccrued Liabilities (Interest, Wages, Taxes, etc.)Supplies on HandPortion of Long Term Debt Due Within One YearStocks and BondsListed (See Schedule B)TOTAL CURRENT ASSETSTOTAL CURRENT LIABILITIESReal EstateLess Depreciation of: $_____ Net (See Schedule A)Liens on Real Estate (See Schedule A) $_____Machinery and Fixtures Less Depreciation of: $_____ NetLess Current Portion Included Above $_____ NetAutomobiles and Trucks Less Depreciation of: $_____ NetStocks and BondsUnlisted (See Schedule B)Capital StockPreferredDue from Partners, Employees, Relatives, Officers, Stockholders of Allied CompaniesCapital StockCommonCash Surrender Value of Life InsuranceSurplusPaid InOther Assets (Described)SurplusEarned and Undivided ProfitsNet Worth (If Not Incorporated) TOTAL TOTALPROFIT AND LOSS STATEMENTFOR THE PERIOD FROM ____________________ TO ____________________RECONCILIATION OF NET WORTH OR EARNEDNet Sales (After Return Sales and Allowances)Net Worth or Earned Surplus at Beginning of PeriodCost of SalesAdd Net Profit or Deduct Net LossBeginning Inventory Total Purchases (or Cost of Goods Mfg)Other Additions (Describe) Total TotalLess: Withdrawals or Dividends Less Closing InventoryOther Deductions (Explain)Gross Profits on SaleTotal DeductionsOperating Expenses: Net Worth or Capital Funds on this Financial Statement SalariesOfficers or PartnersCONTINGENT LIABILITIES (Not Included Above) Salaries and WagesOtherThere are no lease liabilities in existence nor are there assets pledged to secure leases, except as listed in attached schedule. Rent As Guarantor or Endorser or service indebtedness orunder agreements to purchase DepreciationAccounts, Notes, or Trade Acceptances Discounted or Pledged Bad DebtsSurety on Bonds or Other Contingent Liability AdvertisingLetters of Credit InterestJudgments Unsatisfied or Suits Pending TaxesOther Than IncomeLease Liabilities InsuranceMerchandise Commitments and Unfinished Contractors orMerchandise Held on Consignment From Others Other ExpensesUnsatisfied Tax Liens orNotices From the Federal orState Governments ofIntention to Assess Such LiensNet Profit from OperationsDETAIL OF INVENTORY Other IncomeIs Inventory Figure Actual or Estimated? ______________________________ Less Other ExpenseNet Profit Before Income TaxBy Whom Taken or Estimated _______________ When? _______________ Federal and State Income TaxBuy Principally From _____________________________________________Net Profit or LossAverage Terms of Purchase _______________ Sale ____________________(To Net Worth or Earned Surplus)Time of Years Inventory Maximum _____________ Minimum _____________SCHEDULE ALIST OF REAL ESTATE AND IMPROVEMENTS WITH ENCUMBRANCES THEREONDescription, Street Number, LocationTITLE INBOOK TERMS OF VALUEMORTGAGES OR LIENSTERMSHOLDER OF LIENNAMES OFLANDIMPROVEMENTSMATURITYAMOUNTPAYMENT $ $ $ $ TOTALS $ $ $ $SCHEDULE BSTOCKS & BONDS: Describe Fully. Use Supplemental Sheet if Necessary. Indicate if StocksAre Common or Preferred. Give Interest Rate and Maturity of Bonds.NUMBER OF SHARESNAME AND ISSUE (DESCRIBE FULLY)BOOK VALUEMARKET VALUEAMOUNT OF BONDSLISTEDUNLISTEDPRICEVALUE $ $ $ $ $ $SCHEDULE CComplete if Statement is for an Individual or Sole ProprietorshipAge Number of Years in Present Business Date of Filing Fictitious Trade Style What Property Listed in This Statement is in Joint Tenancy? Name of Other Party What Property Listed in This Statement is Community Property? Name of Other Party With What Other Business Are You Connected? Have You Filed Homestead? Do You Deal With or Carry Accounts With Stockbrokers? Amount $Name of Firm SCHEDULE DNAME OF PARTNERS(Indicate Special Partners)AGEAMOUNTCONTRIBUTEDOUTSIDENET WORTHOTHER BUSINESS CONNECTIONSDate of Organization Limited or General? Terminates If Operating Under Fictitious Trade Style, Date of Filing SCHEDULE EComplete if Statement is a CorporationAUTHORIZEDPARVALUEOUTSTANDINGCASHISSUE FOROTHER (DESCRIBE)SHARESAMOUNTBonds─Total Issue $Outstanding Due Interest Rate Date Incorporated Under Laws of State of OFFICERSAGESHARES OWNEDCOMMON | PREFERREDDIRECTORS AND PRINCIPAL STOCKHOLDERSSHARES OWNEDCOMMON | PREFERREDPresident DirectorVice President DirectorSecretary DirectorTreasurerComplete in ALL CasesINSURANCEAre Your Books Audited byOutside Accountants? __________Name _____________________To What Date Has the U.S.Internal Revenue DepartmentDate ofExamined YourLast Audit __________Books? ____________________Are You Borrowing FromAny OtherBranch of This Bank? __________Which? ____________________Are You Applying for CreditAt Any Other Source? __________Where? ____________________If So, Attach a CompleteHave You Ever FailedExplanation and State Basis ofin Business? __________Settlement With CreditorsYears to Run, With MonthlyLease Has __________Rental of $_____ Merchandise __________ $_____ Machinery & Fixtures __________ $_____ Buildings _______________ $_____ Earthquake _______________ $_____ Is Extended Coverage Endorsement Included? __________ Do You Carry Workmen’s Compensation Insurance? Preferred _____ Automobiles and Trucks Public Liability $_____ M/$_____ M Collision _______________ $_____ Property Damage __________ $_____ Life Insurance __________ $_____ Name of Beneficiary ____________________ The undersigned solemnly declares and certifies that the above statement (or in lieu thereof, the attached statement, as the case may be) and supporting schedules, both printed and written, give a full, true, and correct statement of the financial condition of the undersigned of the date indicated. Signature ____________________________________________________________ By _________________________________________________________________ (TITLE, IF CORPORATION) ................
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