Form Ro-1063 - Collection Information Statement For Business Page 3
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6Business Financial Statement- (Rev. 12/09)
Page 3
Accounts/Notes Receivable. Include e-payment accounts receivable and factoring companies, and any bartering or online auction accounts.
(List all contracts separately, including contracts awarded, but not started.)
17. Is the business a Federal or State Government Contractor
Yes
No
(Include Federal or State Government contracts below)
Accounts/Notes Receivable & Address
Status (e.g., age,
Date Due
Invoice Number or Federal or
Amount Due
(Street, City, State, ZIP code)
factored, other)
(mm/dd/yyyy)
State Government Contract Number
18a.
$
Contact Name:
Phone:
18b.
$
Contact Name:
Phone:
18c.
$
Contact Name:
Phone:
18d.
$
Contact Name:
Phone:
18e.
$
Contact Name:
Phone:
18f. Outstanding Balance (Add lines 18a through 18 e and amounts from any attachments)
$
Investments. List all investment assets below. Include stocks, bonds, mutual funds, stock options, and certificates of deposit.
Name of Company & Address
Used as collateral
Current Value
Loan Balance
Equity
(Street, City, State, ZIP code)
on loan
Value Minus Loan
19a.
Yes
No
Phone:
$
$
$
19b.
Yes
No
Phone:
$
$
$
19c. Total Investments (Add lines 19a, 19b, and amounts from any attachments)
$
Available Credit. Include all lines of credit and credit cards.
Amount Owed
Available Credit
Credit Limit
As of
As of
Full Name & Address (Street, City, State, ZIP code) of Credit Institution
mm/dd/yyyy
mm/dd/yyyy
20a.
$
$
$
Account No.
20b.
$
$
$
Account No.
20c. Total Available Credit (Add lines 20a, 20b, and amounts from any attachments)
$
Business Financial Statement- Page 3
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