Debtor Financial Statement Form - Bureau Of Revenue Services

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Compliance Division
24 State House Station
BUREAU OF REVENUE SERVICES
Augusta, Maine 04333-0024
DEBTOR FINANCIAL STATEMENT
(Business)
1. Name and address of business
2. Business phone number
3. (
Check appropriate box)
Sole proprietor
Other (specify)
Partnership
________________________________
Corporation
________________________________
4. Name and title of person being interviewed
5. Employer Identification
6. Type of business
Number
7. Information about owner, partners, officers, major shareholder, etc.
Effective
Phone
Social Security
Total Shares
of
Name and Title
Date
Home Address
Number
Number
I
Section 1.
General Financial Information
8. Latest filed income tax return
Form
Tax Year ended
Net income before taxes
9. Bank accounts
(List all types of accounts including payroll and general, savings, certificates of deposit, etc.)
Type of
Account
Name of Institution
Address
Account
Number
Balance
Total
(Enter in Item 16)
10. Bank credit available
(Lines of credit, etc.)
Credit
Amount
Credit
Monthly
Name of Institution
Address
Limit
Owed
Available
Payments
Totals
(Enter in Items 23 or 24 as appropriate)
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