Financial Information Statement for Businesses
How to Complete This Statement
• Enter the most current data available in all spaces.
• Write N/A in spaces that don’t apply to you. The Taxation and Revenue Department may require
additional information to support N/A entries.
Important
Failure to complete all spaces may result in rejection of this document and/or collection action.
Section 1 1a Business name 2c Type of entity (mark the appropriate box)
Business Sole Proprietorship LLC
1b Business street address
Information Partnership Corporation Other
1c City State ZIP Code 2d Type of business
1d County 1e Business phone (+ area code) 3a Contact name
After you fill in all 2a Employer ID no. (EIN) 2b CRS no. 3b Contact’s business phone (+ area code)
information in Section 1,
mark this box. Ext.
Section 2 4 Owners, Partners, Officers, Major Shareholders, and Others
Business 4a Full name Title Social Security no.
Personnel Home street address Home phone (+ area code)
and Contacts City State ZIP Ownership %age and shares or interest
4b Full name Title Social Security no.
Home street address Home phone (+ area code)
City State ZIP Ownership %age and shares or interest
4c Full name Title Social Security no.
Home street address Home phone (+ area code)
City State ZIP Ownership %age and shares or interest
4d Full name Title Social Security no.
After you fill in all Home street address Home phone (+ area code)
information in Section 2,
mark this box. City State ZIP Ownership %age and shares or interest
Section 3 5 Other Financial Information. Answer the following business financial questions:
Other Financial 5a Does this business have other business relationships (e.g., subsidiary, parent corporation, partnership)? ............... Yes No
Information If Yes, list related EIN Additional EIN
5b Does anyone (e.g., officer, stockholder, partner, employee) have an outstanding loan borrowed from the business? Yes No
If Yes, amount of loan $ Date of loan Current Balance $
5c Are there any judgements or liens against your business? .................................................................................. Yes No
If Yes, who is the creditor?
Date creditor obtained judgement/lien Amount of debt $
5d Is your business a party in a lawsuit? ............................................................................................................... Yes No
If Yes, amount of suit $ Possible completion date
Subject matter of suit
5e Has your business ever filed bankruptcy? .......................................................................................................... Yes No
If Yes, date filed Date discharged Petition no.
5f In the past 10 years, have you transferred any assets from your business name for less than their actual value? ... Yes No
If Yes, what asset? Value of asset at transfer time $
When was it transferred? To whom or where was it transferred?
5g Do you anticipate any increase in business income (e.g., contracts bid but not yet awarded)? ............................... Yes No
If Yes, why will the income increase? If you need more space, attach a sheet.
Amount of increase? $ When will the business income increase?
After you fill in all 5h Is your business a beneficiary of a trust, an estate, or a life insurance policy? ...................................................... Yes No
information in Section 3, If Yes, name of the trust, estate, or policy
mark this box. Amount expected? $ Date to receive this amount?
ACD-31111 Section 4 begins on the next page
int. 01/07/2014