Debtor Financial Statement Form - Bureau Of Revenue Services Page 3

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Section II.
Asset and Liability Analysis
Cur.
Name and Address
Description
Mkt.
Liabilities
Equity in
Amt. of
of Lien/Note
Date
Date of
(a)
Value
Bal. Due
Asset
Mo. Pmt.
Holder/Obligee
Pledged
Final Pmt.
(b)
(c)
(d)
(e)
(f)
(g)
(h)
15. Cash on hand
16. Bank Accounts
17. Accounting/Notes receivable
18. Life insurance loan value
19. Real Property
a.
b.
c.
d.
20. Vehicles (Model, year,
a.
license)
d l
)
b.
c.
21. Machinery & equipment
a.
(specify)
b.
c.
22. Merchandise
a.
inventory (specify)
b.
23. Other Assets
a.
(specify)
b.
24. Other liabilities
a.
(include notes & judgments)
b.
c.
d.
e.
f.
g.
h.
25. Federal taxes owed
26. Total
Page 3 of 4

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