Delayed Deposit Services Financial Statement (Individual) Form - Nebraska Page 2
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1
2
3If more than six
Previous Year
Previous Year
Previous Year
2007
2008
2009
STATEMENT OF INCOME
months
CURRENT YEAR
Salaries, wages, and commissions from employment
$
$
$
$
Income from dividends and investments
Net income from rents, royalties and investments
Other income
TOTAL INCOME
$
-
EXPENSES
=
$
NET INCOME
Supporting Schedules
Schedules set forth below must agree in total with the appropriate item contained in the Financial Statement on Pages 1 and 2 of
this report. Note: Please attach a current balance sheet and statement of income relative to any investment, the value of which is
not readily ascertainable such as closely held corporations, partnerships interests,
tment exceeds 10% of total
etc. when the inves
assets.
Schedule A - Real Estate Owned
Description & Location
Title in Whose Name
Date Acquired
Cost
Insurance
Current Value
$
$
$
$
$
$
$
$
$
$
$
$
$
Carried forward to item 4, Page 1
TOTAL
Schedule B - Marketable Securities
Description
Amount
Description
Amount
$
$
$
$
$
$
$
$
$
$
$
$
Carried forward to item 6, Page 1
TOTAL
$
Page 2 of 3
Rev. 5/2010
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