Business Financial Statement Form 3

FINANCIAL STATEMENT FOR BUSINESSES
Employment Development Department
NOTE: Complete all blocks except “Dept. Use Only” blocks. Write “N/A” (not applicable) in those blocks that do not apply.
Employer Acct. No.:
Bus. Phone: (
Name and Address of Business
)
Federal I.D.#:
Sole Proprietor
Other
Partnership
Corporation – State of Inc.:
Date of Inc.:
CA Corp. I.D.#:
Name, title and telephone number of person completing Financial Statement
Type of Business
List Owner, Partners, Officers, Major Shareholder, etc.
Effective
Date
Name and Title
Home Address
Phone
Number
Social Security
Number
Driver
License #
Current Assets
$
Cash on Hand
Bank Accounts: Include Savings & Loans, Credit Unions, Line of Credit, etc.
Name of Institution
Address
Type of Account
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
DE 926C Rev. 12 (7-03) (INTERNET)
Page 1 of 4
Section A
CU
Current Liabilities
Accounts/Taxes Payable
Name of Tax Agency or Creditor
Address
Dept. Use Only
Balance Due
Mo. Payment
$
$
Section B
Available Credit Sources
Bank Charge Cards, Credit Unions, Savings and Loans, etc.
Type of Account
or Card
Name and Address of
Financial Institution
Amount Owed
$
Minimum Monthly
Payment
$
Business or
Personal
Available
Credit
$
Life Insurance Policies owned with business as a beneficiary
Name Insured
Company
Policy Number
Type
Face Amount
$
Loan Value
$
Market Value
$
Balance Due
$
$
Market Value
$
Balance Due
$
$
Market Value
$
Mortgage Balance
$
Business Assets
Machinery, Furniture, Fixtures, etc.
Description
Equity
Vehicles and Heavy Equipment
Make
Year
License Number
Equity
Real Property Assets
Ownership
Physical Address
County
Dept. Use Only
DE 926C Rev. 12 (7-03) (INTERNET)
Page 2 of 4
Equity
$
Section C
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
Yes
No
Bankruptcies
Yes
No
Repossessions
Yes
No
Participation or beneficiary to trust, estate, etc.
Yes
No
Explanation:
Anticipated increase in business income
Yes
Source
No
If answer is YES give following information:
Date increase is expected and frequency
Amount of increase
$
Recent transfer of business assets of any kind
Description
Receiver
Yes
No
If answer is YES give following information:
Date of Transfer
Fair Market Value
$
Consideration Received
$
Licenses
Board of Equalization
Business License No.
Contractor License No.
Liquor License No.
Other (Specify)
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:
DE 926C Rev. 12 (7-03) (INTRANET)
Date:
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 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 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 IRS and EDD 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. 12 (7-03) (INTERNET)
Page 4 of 4
CU