This document contains a financial statement for a business. It lists the business's assets, liabilities, and financial details such as cash accounts, real estate owned, equipment, accounts receivable, and notes payable. It also includes information about the business owners/officers and their representation that the financial information provided is accurate. The financial statement is intended to obtain loans or other accommodations from lenders.

1. Name:
Address: Phone #:
Business or Occupation: Branches
financial condition of the undersigned on the day of 20
writing will be given you immediately of any materially unfavorable change in the financial condition of the business. In the absence of such notice or a new and
full written financial statement you may consider this statement as continuing and substatially correct and having the same force and effect as id delivered as an
Accounts Receivable of Customer - Good
Inventory How Valued
Time Deposit IRA
$0.00 $0.00
Value of Land
Value of
Buildings
Amount of
Mortgage
Repayment
Terms
Amount of
Insurance
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00 * *
$0.00 $0.00 $0.00 $0.00
yrs
yrs
yrs
yrs
yrs
yrs
yrs
yrs
* yrs
Schedule C Total: $0.00
Schedule C - Fixtures & Equipment
Total * * $0.00$0.00*
See Ext of Equipment * * $0.00
Net Worth (If Individual or Partnership)
$0.00
Total Liabilities
$0.00
Implement Make Age
Total * *
Schedule B Total: $0.00
Condition Cost Present Value
$0.00
See Extension of Real Estate Owned * *
Schedule B - Real Estate Owned
Description of Location Title in Name of Payable to
Schedule A Total: $0.00
Total $0.00 $0.00 $0.00
Schedule A - Cash Accounts
Institution Checking Savings OtherMMD
$0.00
Total $0.00 Total $0.00
$0.00
Other Real Estate
Other Assets (Itemize):
Real Estate Used in Business (Schedule B) $0.00
Notes & Accounts Payable to Partners, Officers,
Stockholders
Mortgage on Real Estate (Schedule B)
Other Liabilities:Stocks, Bonds, & Investments (Attach Detailed List)
Notes Payable - Machinery or Equipment (Schedule D)
Notes Receivable of Partners, Officers or
Stockholders
Assets Liabilities
Cash (Schedule A) $0.00 Accounts Payable
Fixtures & Equipment (Schedule C) $0.00
$0.00
Financial Statement
Business
Notes Payable for Merchandise (Schedule D) $0.00
Notes Receivable of Customers - Good
For the purpose of borrowing money, or otherwise obtaing accomodations from time to time, the undersigned hereby makes the following statement of the
; and it is agreed that notice in
original statement of the financial condition of the business upon application for further borrowings or accomidations.
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00
$0.00
$0.00 $0.00 $0.00 $0.00
$0.00
$0.00 $0.00
$0.00

2. Merchandise Machinery & Equipment
Contingent liabilities: Endorser, guarantor, or surety for others on notes, bonds, contracts, etc. (Give complete details)
Insurance- Amount
Amount
Cash Value $0.00
Beneficiary
Net Sales
Expenses
Note Payments
Date Signed: Signature:
Officers and Directors or Partners
The undersigned hereby represents and warrants that said financial satement and other information given is in all respects true and correct.
If the financial is submitted electronically, a printed name will be used in place of a signature. By printing your name(s) you are certifying the
accuracy of your financial condition. Please have all owners sign/print.
Schedule D Total: $0.00
Total $0.00 * *
For Machinery & Equipment: * * *
Name of Creditor Amount Payment Terms Description of Security
For Merchadise: * * *
Schedule D - Notes Payable Other Than Real estate
$0.00
$0.00 $0.00
Full Name Address Number of Shares Held Worth of Partners Outside
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
OnMerchadise
On Buildings
Amt of Loan, if anyLife (Face Amount)
Is "Merchandise Inventory" based on actual inventory? If so, give date of inventory
Name of predecessor, if anyLength of time you have been in business
Have you ever taken bankruptcy or made a compromise and settlement with your creditors? If so, give details (when , what court)
Are there any judgements unsatisfied or suits pending against you and for what amount?
Name a few concerns from which you purchase in large amounts
$0.00
$0.00
$0.00
$0.00
(Sign Coroporation, Firm or Individual Name Here)
Remaining Income
Income Tax Payments
Gross Profit
Other Fixed Payments
Net Profit
Cost of Sales
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00 $0.00$0.00
$0.00
$0.00
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
PrintSubmit