Commercial Debtor Financial Statement
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4Commercial Debtor Financial Statement
Note: Complete all blocks, except shaded areas. Write “N/A” (not applicable) in those blocks that do not apply.
1 Name and address of business
2 Business phone number
(
)
3 (Check appropriate box)
Sole Proprietor
Other (specify)
Partnership
___________________________________
Corporation
___________________________________
4 Name and title of person being interviewed
5 Employer identification number
6 Type of business
7 Information about owner, partners, officers, major shareholder, etc.
Name of Institution
Effective
Home Address
Phone
Social Security
Total Shares
Date
Number
Number
of Interest
Section I General Financial Information
►
Form
Tax year ended
Net income before taxes
8 Latest filed income tax return
9 Bank accounts (List all types of accounts including payroll and general, savings, certificates of deposit, etc.)
Name of Institution
Address
Type of Account
Account No.
Balance
►
Total (Enter in item 17)…………………………………………………
10 Bank credit available (Line of credit, etc.)
Name of Institution
Address
Credit Limit
Amount Owed
Credit
Monthly
Available
Payments
►
Totals (Enter in items 24 or 25 as appropriate)
11 Location, box number, and contents of all safe deposit boxes rented or accessed.
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Parent category: Financial