Form Ro-1063 - Collection Information Statement For Business Page 2
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6Business Financial Statement- (Rev. 12/09)
Page 2
Section 3. Other Financial Information (Attach copies of all applicable documentation.)
8. Does the business use a Payroll Service Provider or Reporting Agent (If yes, answer the following)
Yes
No
Name and Address (Street, City, State, ZIP code)
Effective dates (mm/dd/yyyy)
9. Is the business a party to a lawsuit ( If yes, answer the following)
Yes
No
Location of Filing
Represented by
Docket/Case No.
Plaintiff
Defendant
Possible Completion Date
(mm/dd/yyyy)
Amount of Suit
Subject of Suit
numeric characters
10. Has the business ever filed bankruptcy ( If yes, answer the following)
Yes
No
Date Filed (mm/dd/yyyy)
Date Dismissed or Discharged (mm/dd/yyyy)
Petition No.
Location
11. Do any related parties (e.g., officers, partners, employees) have outstanding amounts owed
to the business ( If yes, answer the following)
Yes
No
Name and Address
(Street, City, State, ZIP code)
Date of Loan
Current balance
Payment Date
Payment Amt.
as of
$
$
12. Have any assets been transferred, in the last 10 years, from this business for less than full
value ( If yes, answer the following)
Yes
No
List Asset
Value at Time
Petition No.
Location
of transfer
$
13. Does this business have other affiliations (e.g., subsidiary or parent companies)
( If yes, answer the following)
Yes
No
Related Business Name and Address (Street, City, State, ZIP code)
Related Business EIN:
14. Any increase/decrease in income anticipated ( If yes, answer the following)
Yes
No
Explain (use attachment if needed)
How much will it increase/decrease
When will it increase/decrease
$
Section 4. Business Asset and Liability Information
15. Cash on Hand. Include cash that is not in the bank.
Total Cash on Hand
$
Business Bank Accounts. Include online bank accounts, money market accounts, savings accounts, checking accounts, and stored value cards
(e.g., payroll cards, government benefit cards, etc.) List safety deposit boxes including location and contents.
Account Balance
Type of
Full Name and Address (Street, City, State, ZIP code)
Account Number
as of
Account
of Bank, Savings & Loan, Credit Union or Financial Institution
mm/dd/yyyy
16a.
$
16b.
$
16c.
$
16d. Total Cash in Banks (Add lines 16 a through 16c and amounts from any attachments)
$
Business Financial Statement- Page 2
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Parent category: Financial