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Form CM-2B                                    Department of Taxation - State of Hawaii
(Rev. 2020)           STATEMENT OF FINANCIAL CONDITION AND OTHER INFORMATION

Section I.                      General Information - For Corporations, Partnerships, etc. 
1. Name and address of business                                           2.  Business Phone No.       (   )
                                                                          3.  Please check appropriate item:
                                                                               (   )   Corporation     (   )   Partnership
                                                                               (   )   Other (specify)  _____________________

4. Name and title of person being interviewed                          5. Federal I.D. No.                          6.    General Excise I.D. No.

7. Information about owner, partners, officers, major shareholder, etc.
                                              Effective                                                                Home Phone Social Security 
    Name, Title, % ownership, # of shares                                      Home Address
                                              Date                                                                        Number  Number

Section II.                                   General Financial Information
8. Bank account (include Savings & Loans, Credit Unions, IRA and Retirement Plans, Certificate of Deposits, etc.)   
    Attach additional sheets as necessary.
            Name of Institution                         Address                             Type of Account         Account No.   Balance

                                                                                                       Total (Enter in Item 17)
9. Charge cards, bank credit available  (Lines of credit, etc.)  Attach additional sheets as necessary.
Type of Account                                                                Monthly                 Credit             Amount  Credit 
                      Name and address of Financial Institution
   or Card                                                                     Payment                 Limit              Owed    Available

                                              Total (Enter in Item 27)

10.  Safe deposit boxes rented or accessed  (List all locations, box numbers, and contents.)

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Section II.                            General Financial Information  —  continued
11.  Real and lease property  (Brief description and type of ownership)                                           Physical Address (include tax map key)

12.  Life Insurance  (Name of Company)                                  Policy Number            Type                        Face Amount           Available Loan Value

                                                                                                                  Total  (Enter in Item 19)
13.  Securities  (stocks, bonds, mutual funds, money market funds, government securities, etc.)  Attach additional sheets as necessary.
                 Quantity or  
Kind                                    Current Value                                            Where Located                                     Owner of Record
                 Denomination

14.  Additional information regarding financial condition  (Court proceedings, bankruptcies filed or anticipated, transfers of assets for  
less than full value, changes in market conditions, etc.)

15.  Accounts / Notes Receivable  (include current contract jobs, loans to stockholders, officers, partners, etc.)
            Name                                                        Address                                   Amount Due              Date Due      Status

                                                                        Total  (Enter in Item 20)
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Section III.                                       Asset and Liability Analysis
                                                                    Current    Liabilities Equity Amount of 
                              Description                           Market     Balance     in     Monthly 
                                                                    Value      Due         Asset  Payment
ASSETS
16. Cash
17. Bank accounts  (from Item 8)
18. Securities  (from Item 13)
19. Cash or loan value of Insurance  (from Item 12)
20. Accounts / Notes Receivable  (from Item 15)
21. Merchandise Inventory
22. Vehicles  (Model, year, license)
a.
b.
c.
23. Real property  (from Item 11)
a.
b.
c.
24. Machinery and equipment
a.
b.
25. Merchandise inventory
26. Other assets
a.
b.
c.
d.
e.
                                                   Total Assets
LIABILITIES
27. Bank revolving credit  (from Item 9)
28. Loan on Insurance
29. Accounts payable
30. Notes payable
31. Mortgages
32. Judgments
33. Other liabilities
a.
b.
c.
d.
e.
34. Federal taxes owed
35. State taxes owed
                                                   Total Liabilities
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Section IV.                        Income and Expense Analysis  
Income for the period ______________ to ______________            Expenses for the period ______________ to ______________
36. Gross receipts from sales                                     42. Materials purchased
37. Gross rental income                                           43. Net wages and salaries
38. Interest                                                      44. Rent
39. Dividends                                                     45. Supplies
40. Other income (please specify)                                 46. Utilities / Telephone
                                                                  47. Gasoline / Oil
                                                                  48. Repairs and maintenance
                                                                  49. Insurance
                                                                  50. Taxes
                                                                  51. Other  (please specify)

41. Total Income                                                  52. Total Expenses
                                                                  53.  Net difference

Under penalties of perjury, I  (we)  declare that to the best of my  (our)  knowledge and belief this statement of assets, 
liabilities, and other information is true, correct, and complete.
54. Your signature                                                                           55. Date

Additional information or comments:

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