Form Cig-1fs - Financial Statemen-Indiana Department Of Revenue Form

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Indiana Department of Revenue
CIG-1FS
R/5-02
Financial Statement
State Form 49375
From
Office Address
Branch Offices
Business
Location of Plant
To
For the purpose of obtaining loans and discounting paper with you, and otherwise procuring credit from time to time, we for the following, which is and is shown, by
our books to be a true and accurate state of our financial condition on _________________ ________. We agree to and will notify you immediately in writing of any
Year
materially unfavorable change in our financial condition. In the absence of such notice or of a new and full written statement, this may be considered as a continuing
statement and substantially correct; and it is hereby expressly agreed that upon application for further credit, this statement shall have the same force effect as if
delivered as an original statement of our financial condition at the time such further credit is requested.
(Fill all Blanks. Writing “No” or “None” where necessary to complete information.)
Assets
Liabilities
Thousands Hundreds Ones
Thousands Hundreds
Ones
465 46
465
Bills (Notes) Payable Given for Merchandise
646
65
Cash on Hand and in Bank
64654
46 46
654
46
Bills (Notes) Receivable, Good, Due from Customers
Bills (Notes) Payable Negotiated to Banks
Accts. Receivable, Good, Due from Customers
Secured
L.L. Bonds and other Government Securities
Unsecured
Merchandise Finished (How Valued _______)
Bills (Notes) Payable Otherwise Disposed of
Unfinished (How Valued _______)
Open Accounts Payable. Not Due
Raw Material (How Valued _______)
Past Due
Total Quick Assets
Deposits of Money with Us
Machinery and Fixtures
Bills and Accounts Payable
Town or City Real Estate and Buildings
(To Officers and/or stockholders)
Country Real Estate _______ Acres at $_____
Bonded Debt (When due ___________________)
Investments:
Bonds and Stocks
Mortgage Debt
(List on reverse side hereof)
Security Interest in Personal Property
Bills Receivable, Doubtful (Face Value
Reserves (Itemize)
$___________)
Estimated Worth
Bills and Accounts Receivable
(Due from officers and/or stockholders)
Total Liabilities
Capital
Surplus Including Undivided Profits
Total
Total
Specify Any of Above Liabilities Secured as Collateral
Specify Any of Above Assets Pledged as Collateral
Contingent Liability: Notes Receivable of Customers Discounted or Sold and Not included in assets enumerated above
Other Contingent Liability (Specify)
We have not pledged or assigned any of the above accounts receivable. Our assigned accounts receivable amount to
Insurance: On Merchandise $
Buildings $
Machinery $
Total Insurance
Life Insurance Payable to Corporation $
Year
Year
Year
Business and Results: Annual Sales for the year ended
or from
to
Gross Profits on Sales
For the Same Period
Expense of Conducting Business
Net Profit
Other Income including investments
Year
Year
Dividends Paid for the period
to
654654654
Capital:
Authorized
(Par Value $
per share)
Issued $
How Paid in: Cash $
Other Property $
Total
Incorporated under the laws of what state?
Bank Accounts: Where kept
Mortgages and Bonds: On what assets a lien
Average terms on which we Sell
Average Terms on which we Buy
Time of Year when Notes and Accounts Receivable of Customers, Uncollected, are generally maximum
Minimum
Time of Year when Stocks of Merchandise on hand are generally maximum
Minimum
Time of Year when Liabilities are maximum
Minimum
Statement: Is it based on actual inventory?
If so, Date
Verification: Have the books been audited by a Certified Public Accountant?
If so, Name and Date of Audit.
(OVER)

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