Enlarge image | STATE OF DELAWARE DEPARTMENT OF FINANCE BUSINESS COLLECTION INFORMATON STATEMENT DIVISION OF REVENUE [If you need additional space, please attach a separate sheet 820 N. FRENCH STREET with your Business Name & Federal Employer Identification No. WILMINGTON, DE 19801 or Social Security No., if applicable] 1) NAME & ADDRESS OF BUSINESS: 2) BUSINESS PHONE NUMBER: 3) CHECK APPROPRIATE BOX: SOLE PROPRIETOR OTHER (SPECIFY): PARTNERSHIP CORPORATION 4) NAME & TITLE OF PERSON COMPLETING THIS 5) FEDERAL EMPLOYER ID 6) TYPE OF BUSINESS: FORM: NO. OR SOCIAL SECURITY NO. [IF APPLICABLE]: 7) INFORMATION ABOUT OWNER, PARTNERS, OFFICERS, MAJOR SHAREHOLDERS, ETC.: EFFECTIVE PHONE SOCIAL SECURITY TOTAL SHARES NAME & TITLE HOME ADDRESS DATE NUMBER NUMBER OF INTEREST SECTION 1. GENERAL FINANCIAL INFORMATION 8) LATEST FILED INCOME TAX FROM: TAX YEAR ENDED: NET INCOME BEFORE TAXES: RETURN 9) BANK ACCOUNTS: (List all types of accounts, including Payroll and General, Savings, Certificates of Deposits, etc.) TYPE OF ACCOUNT NAME OF INSTITUTION ADDRESS ACCOUNT NUMBER BALANCE 10) BANK CREDIT AVAILABLE: (Lines of Credit, etc.) CREDIT AMOUNT CREDIT MONTHLY NAME OF INSTITUTION LIMIT OWED AVAILABLE PAYMENTS ADDRESS 11) LOCATION, BOX NUMBER AND CONTENTS OF ALL SAFE DEPOSIT BOXES RENTED OR ACCESSED: |
Enlarge image | SECTION 1 (CONT’D) GENERAL FINANCIAL INFORMATION 12) REAL PROPERTY BRIEF DESCRIPTION & TYPE OF OWNERSHIP ADDRESS (INCLUDE COUNTY & STATE) A. B. C. D. 13) LIFE INSURANCE POLICIES OWNED WITH BUSINESS AS BENEFICIARY: POLICY FACE AVAILABLE NAME INSURED COMPANY NUMBER TYPE AMOUNT LOAN VALUE TOTAL (Enter in Item 19) 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. INCLUDE INFORMATION REGARDING COMPANY PARTICIPATION IN TRUSTS, ESTATES, PROFIT-SHARING PLANS, ETC. 15) ACCOUNTS/NOTES RECEIVABLE (Include Loans to Stockholders, Officers, Partners, Etc.): NAME ADDRESS AMOUNT DUE DUE DATE STATUS $ TOTAL $ (Enter in Item 18) |
Enlarge image | SECTION II. ASSETS & LIABILITY ANALYSIS CURRENT LIABILITIES EQUITY IN AMOUNT OF NAME & ADDRESS OF DATE DATE OF DESCRIPTION MKT. VALUE BALANCE DUE ASSET NO. PYMT LEIN/NOTE HOLDER/OBLIGEE PLEDGED FINAL PYMT (a) (b) (c) (d) (e) (f) (g) (h) 16) CASH ON HAND 17) BANK ACCOUNTS 18) ACCOUNTS/NOTES RECEIVALBLE 19) LIFE INSURANCE LOAN VALUE 20) a . b REAL . PROPERTY c . d . a. 21) VEHICLES b. MODEL, YEAR, & LICENSE) c. 22) a. MACHINERY & b. EQUIPMENT (SPECIFY) c. 23) a. MERCHANISE b. IVENTORY (SPECIFY) c. 24) a. OTHER ASSETS (SPECIFY) b. a. 25) b. c. OTHER LIABILITIES d. [INCLUDE NOTES & e. JUDGMENTS f. g. h. 26) TAXES OWED 27) TOTAL |
Enlarge image | SECTION III) INCOME AND EXPENSE ANALSIS THE FOLLOWING APPLIES TO INCOME & EXPENSES ACCOUNTING METHOD USED: DURING THE PERIOD TO INCOME EXPENSES 28) GROSS RECEIPTS FROM SALES, SERV.,ETC. $ 34) MATERIAL PURCHASED $ 35) NET WAGES AND SALARIES 29) GROSS RENTAL INCOME 36) RENT 30) INTEREST 37) INSTALLMENT PAYMENTS 31) DIVIDENDS 38) SUPPLIES 32) OTHER INCOME (SPECIFY) 39) UTILITIES/TELEPHONE 40) GASOLINE/OIL 41) REPAIRS AND MAINTENANCE 42) INSURANCES 43) CURRENT TAXES 44) OTHER (SPECIFY) $ 45) TOTAL 33) TOTAL 46) NET DIFFERENCES CLARIFICATION UNDER PENALTIES 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 COMPLETED. YOUR SIGNATURE TITLE DATE |