FINANCIAL STATEMENT FOR BUSINESSES

NOTE: Complete all blocks except “Dept. Use Only” blocks. Write “N/A” (not applicable) in those blocks that do not apply.

Employer Payroll Tax Account Number: Business Phone:                                   Federal Employer Identification Number:

Name and Address of Business                                            Sole Proprietor               o Other  ________________
                                                                       o
                                                                       o Partnership                        ________________
                                                                       o Corporation – State of Inc.: ________________________
                                                                                       Date of Inc.:  ________________________
                                                                                       CA Corp. ID No.  ________________________
Name, title, and phone number of person completing Financial Statement Type of Business

List Owner, Partners, Officers, Major Shareholder, etc.
                                     Effective                                                        Last 4 Digits of        Driver 
Name and Title                       Date              Home Address                    Phone Number     SSN             License No.

                                                       Current Assets

Cash on Hand                                                                                                           $

Bank Accounts: Include Savings and Loans, Credit Unions, Line of Credit, etc.
Name of Institution                            Address                       Type of Accounts         Account Number    Balance
                                                                                                                       $

Accounts/Notes Receivable
                       Name                                                            Address                          Amount
                                                                                                                       $

Securities: Stocks, Bonds, Mutual Funds, Money Market Funds, Government Securities, etc.
Kind                     Quantity or Denomination                            Where Located                                    Value
                                                                                                                       $

                                                                                       Dept. Use Only   Section A

DE 926C Rev. 15 (7-19) (INTERNET)                      Page 1 of 4                                                            CU

                                                          Current Liabilities
Accounts/Taxes Payable
Name of Tax Agency or Creditor                                          Address                  Balance Due    Mo. Payment
                                                                                                 $              $

                                                                                Dept. Use Only     Section B

                                                Available Credit Sources
Bank Charge Cards, Credit Unions, Savings and Loans, etc.
Type of Account or Card             Name and Address of     Amount Owed         Minimum Monthly  Business or     Available 
                                    Financial Institution                         Payment          Personal      Credit
                                                            $                   $                               $

Life Insurance Policies owned with business as a beneficiary
Name Insured                        Company                   Policy Number       Type          Face Amount      Loan Value
                                                                                               $                $

                                                          Business Assets
Machinery, Furniture, Fixtures, etc.
                                    Description                                 Market Value    Balance Due      Equity
                                                                                $              $                $

Vehicles and Heavy Equipment
Make                                Year                    License Number      Market Value    Balance Due      Equity
                                                                                $              $                $

                                                Real Property Assets

Ownership                           Physical Address          County            Market Value   Mortgage Balance  Equity
                                                                                $              $                $

                                                                                Dept. Use Only     Section C

DE 926C Rev. 15 (7-19) (INTERNET)                           Page 2 of 4                                          CU

                                     Monthly Income and Expense Information

                       Monthly Income                                              Necessary Monthly Operating Expenses
Sales                                          $                         Rent                                             $
Commissions                                                              Utilities
Interest                                                                 Workers’ Compensation Insurance
Dividends                                                                Salaries
Rental Income                                                            Other
Other Income

Dept. Use Only         Section D                                         Dept. Use Only   Section E

            Other Monthly Operating Expenses
Suppliers                                      $
Transportation
Health Insurance
IRS Taxes (Employer portion)
EDD Taxes (Employer portion)
Other

Dept. Use Only         Section F

                                                 General Financial Information

Other information regarding financial condition. If you check the YES box, please give dates and explain below.
Court proceedings                                o Yes o No           Bankruptcies                                        o Yes o No
Repossessions                                    o Yes o No           Participation or beneficiary to trust, estate, etc. o Yes o No
Explanation:

Anticipated increase in business income          o Yes o No              If answer is YES, give following information:
                Source                          Date increase is expected and frequency   Amount of increase
                                                                                         $
Recent transfer of business assets of any kind   o Yes o No              If answer is YES, give following information:
          Description             Receiver/Factoring Company     Date of Transfer     Fair Market Value   Consideration Received
                                                                                   $                     $
Address of Receiver/Factoring Company

                                                        Licenses
CA Department of Tax        Business License No.       Contractor License No.         Liquor License No.       Other (Specify)
and Fee Administration

CERTIFICATION  Under penalty of perjury, I declare that to the best of my knowledge and belief this statement of assets, 
                       liabilities, and other information is true, correct, and complete.
Your Signature:                                                                                          Date:

DE 926C Rev. 15 (7-19) (INTERNET)                            Page 3 of 4                                                        CU

                       HOW TO PREPARE THE FINANCIAL STATEMENT
Complete all requested information. Write “N/A” (not applicable) in those areas that do not apply to your business. If the form 
is incomplete and/or unsigned, we will not be able to consider your request for a payment proposal. The areas explained 
below are those for which specific information must be provided for full disclosure. You may attach additional pages if 
needed.

Current Assets

Bank Accounts – Enter all accounts even if there is currently no balance. DO NOT enter bank loans. You may be requested to 
furnish bank statements for the last six (6) months.
Accounts/Notes Receivable – Enter requested information. Also attach a separate list describing when the receivable is due 
and how frequent (i.e., regular customer or one-time customer). Include anyone who owes the business money. 
Securities – List all stocks, bonds, mutual funds, money market funds, government securities, etc. Include the quantity or 
denomination, where it is located, and the current value.

Current Liabilities

List all creditors and their addresses, the balances due, and the monthly payments, if applicable. You may be requested to 
provide supporting documentation.

Available Credit Sources

List only credit lines or cards by a bank, credit union, or savings and loan that have cash advance features.

Business Assets

Enter all machinery, furniture, fixtures, vehicles, heavy equipment, etc. You may be requested to furnish a list detailing where 
the assets are located, the registered owners and lien holders, and expected payoff dates.

Real Property Assets

List all real estate that is owned or is being purchased. Attach a list of all owners’ names and type of ownership (joint tenants, 
tenants in common), describe the type of mortgage payments and rental income amounts, and what the property is used for 
(residence, vacation, office/shop, rental).

Monthly Income and Expense Information

Monthly Income – Enter gross sales and commissions. Include all interest, dividends, net rental income, and any other 
income.
Necessary Monthly Operating Expenses – Enter ordinary and necessary monthly operating expenses. Attach current profit/
loss statement and balance sheet.
Other Monthly Operating Expenses – Enter the requested information. When entering amounts for Internal Revenue Service 
and Employment Development Department taxes, only give the employer portion of the taxes due. DO NOT include 
amounts withheld from your employee’s wages. You may be requested to provide supporting documentation for all expenses 
claimed.

General Financial Information

Mark the appropriate box. For all “yes” answers, enter full explanation. Attach additional pages if necessary.

Licenses

Provide license number for all licenses held.

DE 926C Rev. 15 (7-19) (INTERNET)                        Page 4 of 4                                          CU