Financial Statement Form - Commercial Driver'S License Application And Renewal Form

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Wisconsin Department of Transportation
FINANCIAL STATEMENT
Financial Statement Date
MV2195
11/2000
s.345.17 or s.946.32 Wis. Stats.
The figures in this financial statement show assets and liabilities as of the specific date shown above, which MUST be within the past 90 days.
License Numbers of ALL Dealerships
Area Code - Telephone Number
Legal Name
Business Address
Post Office Box Number
City
State
Zip Code
Business Entity
Sole Proprietorship
Name and Title of Owner, Partners, Association Members, Corporation Officers and Shareholders, LLC Managers and Members
Partnership
Corporation
Association
LLC
ASSETS
LIABILITIES
Amount
Amount
$
$
1.
Cash on Hand - Not cash in bank
43. Accounts Payable
2.
Cash in ___________________
44. Notes Payable - Bank, Schedule C
Show name
{
3.
Cash in ___________________
of bank
45. Notes Payable - Other, Schedule C
4.
Securities Owned - Complete Schedule A
46. Customer deposits on motor vehicles
5.
Contracts in Transit - No. _____________
to be delivered, Attach itemized list
Receivables
47. Dividends Declared - Not Paid
6.
Time contracts dealer holds on MVs or RVs
48. Accrued Payroll
7.
Time contracts dealer holds on merchandise
49. Accrued Taxes or Rent
8.
Open Accounts less than 90 days
50. Social Security, U.C., Withholding
9.
Open Accounts past due
51. Sales Tax Owed
10. Others - Describe
52. No. _____ New cars, cycles, RVs or
Inventories- At lower of cost or book
Mopeds, Floor-Planned *
11. No. _____ New cars, cycles, RVs or Mopeds
53. No. _____ New trucks, Floor-Planned *
12. No. _____ New trucks
54. No. _____ Implements, Floor-Planned *
13. No. _____ Implements
55. No. _____ Demonstrators, Floor-Planned *
14. No. _____ Demonstrators
56. No. _____ Used vehicles, Floor-Planned *
15. No. _____ Used vehicles
* List in Schedule D
16. New Parts
57. Other Liabilities, including contingent liabilities
17. Accessories
58. Total Lines 43-57 inclusive
$
18. Gas, oil, grease
Mortgages Payable On: Schedule B
19. Other Inventory - Describe
59. Land and Buildings - Dealer Business
20. ___________________________________
60. Land and Buildings - Other
21. ___________________________________
61. Machinery, Tools and Equipment
Prepaid Expenses
62. Office Furniture and Fixtures
22. Taxes and Interest
63. Leased Vehicles
23. Rent and Insurance
64. Other ______________________________
24. Other Prepaid Expenses
65. Judgments Outstanding
25. Total Lines 1-24 inclusive
$
Depreciation/Amoritzation Reserve, Sch. B
Fixed Assets- Complete Schedule B
66. Land and Buildings - Dealer Business
26. Land and Buildings - Dealer Business
67. Land and Buildings - Other
27. Land and Buildings - Other
68. Amortization of Leaseholds
28. Leasehold Improvements
69. Machinery, Tools and Equipment
29. Machinery, Tools and Equipment
70. Office Furniture and Fixtures
30. Office Furniture and Fixtures
71. Leased Vehicles
31. Leased Vehicles
72. Other ______________________________
Deferred Assets
73. Total Liabilities & Reserves Lines 58-72 incl.
$
32. Deposits on contracts
Net Worth
33. Factory reserve or bonus
74. Capital Stock
34. Finance reserve including holdbacks
75. Treasury Stock - if any
35. Officers notes and accounts (corporation)
76. Partners' Investments - partnership
36. Advances to employes
77. LLC Members' Contributions
37. Others _____________________________
$
78. Surplus beginning of year
Other Assets Not Listed Above
79. Profit this year
38. ___________________________________
80. Total Lines 78-79 incl.
39. ___________________________________
81. Less Div./Dist. Declared
40. ___________________________________
82. Total Surplus
41. ___________________________________
83. Net Worth
42. Total Assets (Lines 25-41 inclusive)
$
84. Total Lines 73+83 (Equals Total Assets)
$

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