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Entity name
Federal ID Number *216921500*
*216921500*
Page 5
SECTION 5 OTHER INFORMATION
Please provide the additional information requested, which is needed to understand your financial situation.
A. Is the business currently in bankruptcy? ................................................ Yes No
B. Has the business ever filed bankruptcy? ................................................ Yes No
If “Yes,” Date Filed (mmddyyyy) ________________ Date Dismissed or Discharged (mmddyyyy) ______________
Petition No. __________________________________ Location __________________________________________
C. Does this business have other business affiliations (e.g., subsidiary or parent companies)? ......... Yes No
If “Yes,” Name ___________________________________________________
Employer Identification Number _____________________________________
D. Do any related parties (e.g., partners, officers, employees) owe money to the business? ........... Yes No
E. Has the business been party to a lawsuit? ............................................... Yes No
F. In the past 10 years, has the business transferred any assets for less than their full value? .......... Yes No
G. Has the business been located outside the U.S. for 6 months or longer in the past 10 years? ........ Yes No
H. Does the business have any funds being held in trust by a third party? ......................... Yes No
I. Does the business have any lines of credit? .............................................. Yes No
If “Yes,” Credit limit: $ _________________________ Amount owed: $ ____________________________________
What property secures the line of credit? __________________________________________ ______________________
SECTION 6 SIGNATURES
Under penalties of perjury, I declare that I have examined this offer, including accompanying documents, and to the best of my knowledge, it is true,
correct, and complete.
Signature of Responsible Officer Title Date
Printed name Email address
Remember to include all applicable attachments from list below.
A current Profit and Loss statement covering at least the most recent 6-12 month period, if appropriate.
Copies of the three most recent statements for each bank, investment, and retirement account.
If an asset is used as collateral on a loan, include copies of the most recent statement from lender(s) on loans, monthly
payments, loan payoffs, and balances.
Copies of the most recent statement of outstanding notes receivable (if applicable).
Copies of the most recent statements from lenders on loans, mortgages (including second mortgages), monthly payments,
loan payoffs, and balances.
Copies of accountant’s depreciation schedules, if applicable.
Documentation for any claims of exceptional circumstances. Examples of possible documentation to include are: copies
of actual monthly expenses, out-of-pocket medical expenses, physician’s statements detailing illness, etc.
Attach a Form PA-1, Power of Attorney, if you would like your attorney, account or tax preparer, or other party to represent
you and you do not have a current form on file with the Vermont Department of Taxes.
Form TAX-692
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5454 Rev. 09/21
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