Delayed Deposit Services Financial Statement (Individual) Form - Nebraska
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Delayed Deposit Services Financial Statement (Individual)
Nebraska Department of Banking and Finance
Commerce Court
1230 "O" Street, Suite 400
PO Box 95006
Lincoln, NE 68509-5006
402-471-2171
Name: _____________________________________Daytime Telephone: _______________________________________________
Address: ___________________________________________________________________________________________________
This Financial Report and the information herein is a correct and complete statement of the financial condition of the above named
individual as of _____________________________, 20 ____. This information is submitted to the Nebraska Department of Banking
and Finance for its confidential use, in connection with the Delayed Deposit Services Business Application of:
__________________________________________________________________________________________________________
NOTE: An answer to each item is required. If th
e answer is "No", "None", or "Not applicable"
so state. If an item of information called for is
unknown, so state. If space provided on this form is not adequate, attach a separate schedule. All such schedules should be signed and dated.
ASSETS
LIABILITIES
1)
Cash on hand and in banks
$
9)
Accounts payable
$
2)
Notes, loans, & other accounts receivable
10)
Notes payable to banks - from Schedule
$
$
considered good & collectable
D
3)
Merchandise & inventory at lower of cost or
11)
Notes payable to others - from Schedule
$
$
market value
E
Real estate mortgages - from Schedule
4)
Real estate - from Schedule A
12)
$
$
F
5)
Machinery & equipment - at cost less
13)
Interest and taxes due and unpaid- from
$
$
depreciation
Schedule G
Other debts and liabilities - from
6)
Marketable securities - from Schedule B
14)
$
$
Schedule H
7)
Life insurance (face amount
$
$
TOTAL LIABILITIES
$ _________ ) cash surrender value
8)
Other assets - from Schedule C
$
15)
NET WORTH
$
TOTAL LIABILITIES and NET
$
$
TOTAL ASSETS
WORTH
NOTE: Estimated value of notes, accounts receivable, mortgages, and other
$
assets considered doubtful and not included in above financial statement:
CONTINGENT LIABILITIES (If none, so state)
ently
In addition to the debts and liabilities listed above, have you endorsed, guaranteed, or become otherwise indirectly or conting
liable for the debts of others?
? Yes
? No
If "yes", give details in the following schedule
Date Obligation
Name and address of
Name and address of
Value of
Current
Description of Collateral
Incurred
Due
Debtor or Obligator
Creditor or Obligee
Collateral
Amount
$
$
$
$
$
$
$
$
TOTAL
$
For use by the Department of Banking and
Finance only:
Page 1 of 3
Reviewed
by:_________________________________
Rev. 5/2010
Date: _______________________________________
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