Form Eg-13-B Financial And Other Information Statement For Businesses
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Illinois Department of Revenue
EG-13-B
Financial and Other Information Statement for Businesses
Note:
We may require support for amounts shown on this form.
Step 1: Tell us about your business
1
Business name ______________________________________________________________________________
Address ____________________________________________________________________________________
____________________________________________________________________________________
City
State
Zip
2
Business phone (____)______________________
3
Federal employer identification number (FEIN) ____ ____ - ____ ____ ____ ____ ____ ____ ____
4
Illinois account ID _____________________________________
Step 2: Tell us about your bank accounts and credit card receivables
Attach additional sheets in the same format, if necessary.
a Bank accounts (include payroll and general, savings, certificates of deposit, etc.)
A
B
C
D
E
Name of institution
Address
Type of account
Account number
Balance
5
__________________
______________________________________________
________________
________________
________________
6
__________________
______________________________________________
________________
________________
________________
b Current credit card processor and associated receivables
A
B
C
Name of credit card processor
Address
Current receivables
7
__________________________
________________________________________________
______________
8
__________________________
________________________________________________
______________
Step 3: Tell us about your real property
Attach additional sheets in the same format, if necessary.
A
B
C
D
Brief description of property
Type of ownership
Physical address
County
9
_ ____________________________________
___________________
___________________________________________
________________
10
_ ____________________________________
___________________
___________________________________________
________________
Step 4: Tell us if bankruptcy is pending
11
Are foreclosure, bankruptcy, receivership, or assignment for benefit of creditors proceedings pending? ____yes ____no
12
Bankruptcy number ____________________________________
13
Date filed ___ ___/___ ___ /___ ___ ___ ___
Month
Day
Year
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EG-13-B front (R-5/12)
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Parent category: Financial