California Form 3555l - Request For Tax Clearance Certificate - 2004 Page 3
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4FINANCIAL STATEMENT FOR INDIVIDUAL OR OTHER ENTITY
Closing or disappearing business entity’s name
California corporation or SOS file number
Statement of Assets and Liabilities
Present
Liabilities
Equity in
Item
Value (A)
Balance Due (B)
Asset
Cash
Bank accounts
Stocks and bonds
Cash or loan value of insurance
Household furniture
Real property
Vehicles
Other assets (describe)
Federal taxes outstanding
Loans
Other (include judgements)
Net assets
$
(Total column A less total column B)
General Information (Attach additional schedules if necessary.)
Net annual income
Source (name of business or employer)
Banks and savings and loan accounts (names and addresses)
Description and license number of each vehicle
Stocks and bonds (name of company, number of shares, etc.)
Real property (brief descriptions and locations)
I certify that the information above is correct to the best of my knowledge.
Assumer’s name (print) _____________________________________________________________________________________________________
Assumer’s address ____________________________________________________________ Phone number (
) _______________________
Assumer’s signature __________________________________________________________________________ Date _______________________
FTB 3555L C1 (REV 10-2004) PAGE 3
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