Business Financial Statement Form

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BUSINESS FINANCIAL STATEMENT
The purpose of this form is to evaluate your ability to pay the amounts which you owe. Based upon the information you
provide, a determination will be made as to what payment terms are appropriate and acceptable. Information on this form
may be used for collection purposes in the event of a default on any agreement reached. You are not legally required to
provide the information requested on this form. However, if you fail to do so, your request for settlement may be denied.
This form is for the use of the Department of Economic Security only.
Business Name:
U.I. Account No.
Address:
Telephone No.
Type of Business:
[
] Corporation
[
] Partnership
[
] Proprietor
PARTNERS OR OFFICERS
Name
% of Ownership
Social Security No.
1.
Address:
2.
Address:
3.
Address:
4.
Address:
5
Address:
ASSETS
A. Checking and Savings (List Bank, Bank Account No. and Addresses):
1.
2.
3.
B. Motor Vehicles (Give License Number, Year and Make of Each Vehicle Owned or Leased):
1.
Security Interest
[ ] Yes [ ] No
(Motor Vehicle)
(Market Value)
2.
Security Interest
[ ] Yes [ ] No
(Motor Vehicle)
(Market Value)
3.
Security Interest
[ ] Yes [ ] No
(Motor Vehicle)
(Market Value)
DJT-1853 (Rev. 1/5/95)

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