Form Eg-13-B - Financial And Other Information Statement For Businesses - 2011
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Illinois Department of Revenue
EG-13-B
Financial and Other Information Statement for Businesses
Note:
We may require support for amounts shown on this form.
Step 1: Tell us about your business
1
7
Business name _______________________________________
List partners or officers. Attach an additional sheet, if necessary.
Address _____________________________________________
Name _______________________________________________
____________________________________________________
Address _____________________________________________
City
State
ZIP
____________________________________________________
2
Federal employer identification number (FEIN)
Number of shares or interest _____________________________
____ ____ - ____ ____ ____ ____ ____ ____ ____
Social Security number or FEIN __________________________
3
Illinois account ID
____________________________________________________
Name _______________________________________________
4
Business phone (____)______________________
Address _____________________________________________
5
Estimated average net income for the next six months
____________________________________________________
$___________________________________________________
Number of shares or interest _____________________________
6
Net income for past two years $___________________________
Social Security number or FEIN __________________________
Step 2: Tell us about your bank accounts and credit card receivables
Attach additional sheets in the same format, if necessary.
a Bank accounts (include payroll and general, savings, certificates of deposit, etc.)
A
B
C
D
E
Name of institution
Address
Type of account
Account number
Balance
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__________________
______________________________________________
________________
________________
________________
9
__________________
______________________________________________
________________
________________
________________
b Current credit card processor and associated receivables
A
B
C
Name of credit card processor
Address
Current receivables
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__________________________
________________________________________________
______________
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__________________________
________________________________________________
______________
Step 3: Tell us about your real property
Attach additional sheets in the same format, if necessary.
A
B
C
D
Brief description of property
Type of ownership
Physical address
County
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_ ____________________________________
___________________
___________________________________________
________________
13
_ ____________________________________
___________________
___________________________________________
________________
Step 4: Tell us about your charge cards or credit lines from banks, credit unions,
and savings and loans
Attach additional sheets in the same format, if necessary.
A
B
C
D
Type of account or card
Name and address of financial institution
Credit limit
Credit available
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__________________________
________________________________________________
______________
______________
15
__________________________
________________________________________________
______________
______________
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__________________________
________________________________________________
______________
______________
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__________________________
________________________________________________
______________
______________
Step 5: Tell us about your life and health insurance policies
Attach additional sheets in the same format, if necessary.
A
B
C
D
E
Face
Available
Insurance company
Policy number
Type
amount
loan value
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_________________________________
_________________
_____________________
______________
______________
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_________________________________
_________________
_____________________
______________
______________
Step 6: Tell us if bankruptcy is pending
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Are foreclosure, bankruptcy, receivership, or assignment for
Have you disposed of any assets or property by sale, transfer,
benefit of creditors proceedings pending? ____yes ____no
exchange, gift, or in any other manner except for full value from
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Bankruptcy number ____________________________________
the beginning of the period in which the liability was incurred to
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Date filed ___ ___/___ ___ /___ ___ ___ ___
the present date? ____yes ____no
If yes, attach a separate
Month
Day
Year
statement showing amounts, dates, circumstances, etc.
EG-13-B front (R-3/11)
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Parent category: Financial