Form Mf-43 - Financial Statement - Kansas Department Of Revenue
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2KANSAS DEPARTMENT OF REVENUE
CUSTOMER RELATIONS
915 SW HARRISON ST.
TOPEKA, KANSAS 66625-8000
Inside Topeka: (785) 368-8222
Outside Topeka Call Toll Free: 1-877-526-7738
FAX (785) 296-4993
FINANCIAL STATEMENT
To accompany application for manufacturer’s, importer’s, distributor’s, special fuel dealer-user’s or LP-gas user-dealer’s license. If partnership, each partner
must prepare a separate financial statement. This statement prepared on behalf of: individual [ ], partner [ ], partnership [ ], corporation [ ], other [ ].
Business Name:
Address:
TO: Motor Fuel Tax Correspondence, Kansas Department of Revenue, 915 SW Harrison St., Topeka, Kansas 66625-8000.
DEAR SIR: As a basis of information for the Director of Taxation in determining the amount of bond required before the granting of a license, the following
financial statement is submitted as of
20
.
Amount of Company
NAMES OF PARTNERS IF A PARTNERSHIP, OR OFFICERS, IF A CORPORATION
Official Title if Any
Stock or Partnership
Interest Owned by Each
Name
Name
Name
ASSETS
LIABILITIES
Cash on Hand and in Bank......................................
$
Notes Payable—To Whom ...................................
$
Merchandise on Hand, Cash Value.........................
Notes Receivable—Good........................................
Accounts Payable—Due .......................................
Accounts Receivable—Good..................................
Accounts Payable—Not Due ................................
Government Bonds and Savings Stamps ................
Owing to Banks—What Bank ..............................
Other Stocks and Bonds..........................................
Accrued Motor Fuel Tax ......................................
Real Estate as Listed on Reverse Side ....................
Accrued Other Taxes ............................................
Personal Property and Equipment...........................
Mortgages on Real Estate—Reverse Side ............
Other .......................................................................
Liens or Encumbrances on Personal Property ......
Capital Stock Paid Up—If Incorporated...............
Other Obligations .................................................
Surplus and Undivided Profits..............................
Net Worth .............................................................
Total ......................................................
$
Total ....................................................
$
INSURANCE: On Merchandise $
Buildings $
Equipment $
Total Insurance $
BUSINESS LIFE INSURANCE: To Whom Payable
Amount $
BANK ACCOUNTS: Where Kept?
What do you estimate your monthly tax liability to the Department of Revenue will be? $
Do you have lawsuits pending?
Did your Surety Company require you to post security?
How much?
Do you have any judgments against you?
By Whom?
Have you ever taken advantage of the bankruptcy laws of the United States?
When?
From whom do you buy your motor-vehicle fuels?
STATE OF
,
COUNTY OF
, SS.:
I do solemnly swear that the above statement is true and correct.
(Signature)
(Title)
Subscribed and sworn to before me, this
day of
20
My commission expires
20
Notary Public
MF-43 (Rev. 12/01)
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