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               Illinois Department of Revenue

               BOA-5           Financial Information Statement for Businesses

Section 1: Tell us about your corporation or partnership

Part A: Corporation or partnership information

1 Business name________________________________________        5 Federal employer identification number (FEIN)

2 Street address ________________________________________        ____   ____ -  ____   ____   ____   ____   ____   ____   ____

   ____________________________________________________        6 Illinois business tax (IBT) number ___  ___  ___  ___ -  ___  ___  ___  ___
   City                        State    ZIP

3 Telephone number (_____)______________________________       7 Name of bank for business_________________________________

4 Check the appropriate box      Active   Dissolved            8 Estimated average net income for the next six months $__________

   Date of incorporation ___  ___/___  ___/___  ___  ___  ___  9 Have you disposed of any assets or property by sale, transfer,
                         Month Day      Year                   exchange, gift, or in any other manner except for full value from the
   Renewal date          ___  ___/___  ___/___  ___  ___  ___    beginning of the taxable period in which the liability was incurred to
                         Month Day      Year                   the present date?                  Yes          No
   Date dissolved         ___  ___/___  ___/___  ___  ___  ___ If “yes,” attach separate statements to show amounts, dates, and
                         Month Day      Year                   circumstances.

Part B: Officers or partners information
                  ABCD
                                                                                 Number of
               Name and title                   Address                          shares               Social Security number

10 _______________________________      _________________________________        ________             __ __ __  -  __ __  -  __ __ __ __

11 _______________________________      _________________________________        ________             __ __ __  -  __ __  -  __ __ __ __

12 _______________________________      _________________________________        ________             __ __ __  -  __ __  -  __ __ __ __

13 _______________________________      _________________________________        ________             __ __ __  -  __ __  -  __ __ __ __

14 _______________________________      _________________________________        ________             __ __ __  -  __ __  -  __ __ __ __

Section 2: Complete the following financial information
Note: Attach additional sheets in the same format for any of the following parts if necessary.
Part A: Bank accounts (include payroll and general, savings, certificates of deposit, etc.                        )
               ABCDE
                                                                                 Type of              Account
   Name of institution                  Address                                  account              number       Balance

15 _________________        ___________________________________________      ___________              ___________ ____________

16 _________________        ___________________________________________      ___________              ___________ ____________

17 _________________        ___________________________________________      ___________              ___________ ____________

18 _________________        ___________________________________________      ___________              ___________ ____________

19 _________________        ___________________________________________      ___________              ___________ ____________

20 Add Lines 15 through 19, Column E, and write the total here and on Part F, Line 36, Column D.              20  ____________
BOA-5 (R-1/01)                                                                                                     Page 1 of 4

Part B: Charge cards or credit lines from banks, credit unions, and savings and loans

            ABC
            Type of account                                                                                                Current
            or card                                       Name and address of financial institution                        balance

21 ______________________     __________________________________________________________________                         ____________

22 ______________________     __________________________________________________________________                         ____________

23 ______________________     __________________________________________________________________                         ____________

24 ______________________     __________________________________________________________________                         ____________

25 ______________________     __________________________________________________________________                         ____________

26 Add Lines 21 through 25, Column C, and write the total here and on Part F, Line 38, Column C.                      26 ____________

Part C: Real property
            AB                                                                               C D
            Brief description             How property
            of property                   is titled                                 Physical address                       County

27 ______________________     _________________________              ______________________________________              ____________

28 ______________________     _________________________              ______________________________________              ____________

29 ______________________     _________________________              ______________________________________              ____________

Part D: Life and health insurance policies
                              A                                              BCDE
                                                                             Policy                              Face      Available
                        Insurance company                                   number           Type           amount       loan value

30 __________________________________________________                ___________    ___________             ___________  ___________

31 __________________________________________________                ___________    ___________             ___________  ___________

32 Add Lines 30 and 31, Column E, and write the total here and on Part F, Line 41, Column D.                          32 ___________

Part E: Miscellaneous information

33 a Are foreclosure, bankruptcy, receivership, or assignment for benefit of creditors proceedings pending?       Yes    No

   b What is the bankruptcy number?  _______________________

   c What date was the bankruptcy filed?___  ___/___  ___/___  ___  ___  ___  If closed, what was the date?___  ___/___  ___/___  ___  ___  ___
                                        Month         Day       Year                                       Month Day       Year
34   Please identify the preparer of your tax returns.

     __________________________________________________________________                      (____)____________________________
     Preparer’s name                                                                         Telephone
     __________________________________________________________________
     Street address
     __________________________________________________________________
     City                                                 State              ZIP

Page 2 of 4                                                                                                                BOA-5 (R-1/01)

Note: You may submit copies of your most recent corporate financial statements (i.e., income statement, balance sheet, and
statement of assets) instead of completing Parts F and G.

Part F: Asset and liability analysis

               A           BCDE                                                      F                   G
                                                         Equity          Monthly                         Date of
                           Fair market Liabilities       (Column B minus payment                         final
         Description       value       balance due       Column C)       amount       Pledgee or obligee payment

35 Cash                    __________  ___________       ___________     ___________ __________________  ___________
36 Total bank accounts
   from Section 2, Part A,
   Line 20                 __________  ___________       ___________     ___________ __________________  ___________
37 Accounts/notes
   receivable              __________  ___________       ___________     ___________ __________________  ___________
38 Total charge cards
   balance from Section 2,
   Part B, Line 26         __________  ___________       ___________     ___________ __________________  ___________
39 Vehicles (model, year)
a ___________________      __________  ___________       ___________     ___________ __________________  ___________
b ___________________      __________  ___________       ___________     ___________ __________________  ___________
c ___________________      __________  ___________       ___________     ___________ __________________  ___________
40 Real property listed
   in Section 2,
   Part C, (Line 27)       __________  ___________       ___________     ___________ __________________  ___________
           (Line 28)       __________  ___________       ___________     ___________ __________________  ___________
           (Line 29)       __________  ___________       ___________     ___________ __________________  ___________
41 Total cash or loan value
   of insurance from
   Section 2, Part D,
   Line 32                 __________  ___________       ___________     ___________ __________________  ___________
42 Machinery and
   equipment (specify)
a ___________________      __________  ___________       ___________     ___________ __________________  ___________
b ___________________      __________  ___________       ___________     ___________ __________________  ___________
c ___________________      __________  ___________       ___________     ___________ __________________  ___________
43 Merchandise inventory
   (specify)
a ___________________      __________  ___________       ___________     ___________ __________________  ___________
b ___________________      __________  ___________       ___________     ___________ __________________  ___________
44 Other assets (specify)
a ___________________      __________  ___________       ___________     ___________ __________________  ___________
b ___________________      __________  ___________       ___________     ___________ __________________  ___________
c ___________________      __________  ___________       ___________     ___________ __________________  ___________
d ___________________      __________  ___________       ___________     ___________ __________________  ___________
45 Other liabilities not
   covered above (include
   judgments and notes)
a ___________________      __________  ___________       ___________     ___________ __________________  ___________
b ___________________      __________  ___________       ___________     ___________ __________________  ___________
c ___________________      __________  ___________       ___________     ___________ __________________  ___________
d ___________________      __________  ___________       ___________     ___________ __________________  ___________
46 Federal taxes owed      __________  ___________       ___________     ___________ __________________  ___________
47 State taxes owed
   a Illinois business
     income tax            __________  ___________       ___________     ___________ __________________  ___________
   b Other state taxes     __________  ___________       ___________     ___________ __________________  ___________

48 Total                   __________  ___________       ___________     ___________ __________________  ___________

BOA-5 (R-1/01)                                                                                           Page 3 of 4

Part G: Monthly income and expense analysis

                                                                                                                               Necessary monthly
                                  Income                                                                                       operating expenses
            ABCA B
   Source                         Gross                          Net               Expense                                                                        Amount

49 Gross receipts from                                                          55 Rent (not included
   sales, services, etc.  ___________________         ___________________          in Part F, Line 40)                            ___________________
50 Gross rental income    ___________________         ___________________       56 Net wages and salaries
51 Interest               ___________________         ___________________          (no. of employees_____)                        ___________________
52 Dividends              ___________________         ___________________       57 Materials purchased                            ___________________
53 Other income (specify)                                                       58 Repairs and maintenance                        ___________________
   ________________       ___________________         ___________________       59 Supplies                                       ___________________
   ________________       ___________________         ___________________       60 Installment pmts. from
   ________________       ___________________         ___________________          Part F, Line 48, Col. E                        ___________________
   ________________       ___________________         ___________________       61 Utilities/telephone                            ___________________
   ________________       ___________________         ___________________       62 Gasoline/oil                                   ___________________
   ________________       ___________________         ___________________       63 Insurance                                      ___________________
   ________________       ___________________         ___________________       64 Current taxes                                  ___________________
   ________________       ___________________         ___________________       65 Other (specify)
   ________________       ___________________         ___________________          __________________                             ___________________
   ________________       ___________________         ___________________          __________________                             ___________________
   ________________       ___________________         ___________________          __________________                             ___________________
                                                                                66 Add Lines 55 through 65.
54 Add Lines 49 through 53, Column C.                                              This amount is your
   This amount is your total net income.              ___________________          total expenses.                                ___________________

67 Subtract Line 66 from Line 54. This amount is your net income after expenses.                                               67 ___________________

Part H: Complete any additional asset or income information
68 Write any additional information you have about your assets or income that was not included in any of the preceding parts. Be sure to
   include a statement regarding the prospect of any increase in the value of your assets or your present income.

   ________________________________________________________________________________________________________

   ________________________________________________________________________________________________________

   ________________________________________________________________________________________________________

   ________________________________________________________________________________________________________

   ________________________________________________________________________________________________________

   ________________________________________________________________________________________________________

   ________________________________________________________________________________________________________

Section 3: Sign below

Under penalties of perjury, I state that I have examined this statement of assets, liabilities, and other information and, to the best of my
knowledge, it is true, correct, and complete.

_______________________________________________________          ___________________________________                                                              ____/____/_______
Authorized corporate officer's or parner's signature             Title                                                                                            Date

                    This form is authorized as outlined by the Illinois Income Tax Act. Disclosure of this information is REQUIRED. Failure to provide information
Page 4 of 4         could result in this form not being processed. This form has been approved by the Forms Management Center. IL-492-3684                        BOA-5 (R-1/01)

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