Form Ro-1063 - Collection Information Statement For Business Page 6
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6Business Financial Statement- (Rev. 12/09)
Page 6
Business Liabilities. Include notes and judgments below.
Date of Final
Business Liabilities
Secured/
Date Pledged
Balance Owed
Payment
Payment
Unsecured
(mm/dd/yyyy)
(mm/dd/yyyy)
Amount
24a. Description
Secured
Unsecured
$
$
Name
Street Address
City/State/ZIP code
Phone:
24b. Description
Secured
Unsecured
$
$
Name
Street Address
City/State/ZIP code
Phone:
24c. Description
Secured
Unsecured
$
$
Name
Street Address
City/State/ZIP code
Phone:
$
$
24d. Total Balance Owed
24e. Total Payments
Section 5. Monthly Income/Expense Statement for Business
Accounting Method Used:
Cash
Accrual
Income and Expenses during the period (mm/dd/yyyy)
to (mm/dd/yyyy)
Total Monthly Business Income
Total Monthly Business Expenses
Source
Gross Monthly
Expense Items
Actual Monthly
25 Gross Receipts from Sales/Services
36 Materials Purchased
26 Gross Rental Income
37 Inventory Purchased
27 Interest Income
38 Gross Wages & Salaries
28 Dividends
39 Rent
29 Cash
40 Supplies
Other Income (Specify below)
41 Utilities/Telephone
30
42 Vehicle Gasoline/Oil
31
43 Repairs & Maintenance
32
44 Insurance
33
45 Current Taxes
34
46 Other Expenses (Specify)
35 Total Income
47 DOR Use Only
(Add Lines 25 through 34)
Allowable Installment Payments
48 Total Expenses
(Add Lines 36 through 47)
Materials Purchased: Materials are items directly related to the production of a
Utilities/Telephone: Utilities include gas, electricity, water, oil, other fuels,
a product or service.
trash collection, telephone and cell phone.
Inventory Purchased: Goods bought for resale.
Current Taxes: Real estate, state, and local income tax, excise, franchise,
Supplies: Supplies are items used to conduct business and are consumed or used up
occupational, personal property, sales and the employer's portion of the
within one year. This could be the cost of books, office supplies, professional equipment .
the employment taxes.
Under penalties of perjury, I declare that to the best of my knowledge and belief this
Certification
statement of assets, liabilities, and other information is true, correct and complete.
Signature
Title
Date
Print Name of Officer, Partner or LLC Member
Attachments Required:
Copies of the following items for the last 3 months from the date this form is submitted (check all attached items):
Banks and investments- Statements for all money market, brokerage, checking/savings accounts, certificates of deposit, stocks/bonds.
Assets- Statements from lenders on loans, monthly payments, payoffs, and balances, for all assets. Include copies of UCC financing
statements and accountant's depreciation schedules.
Expenses- Bills or statements for monthly recurring expenses of utilities, rent, insurance, property taxes, telephone and cell phone,
insurance premiums, court orders requiring payments, other expenses.
Other- credit card statements, profit and loss statements, all loan payoffs, etc.
Copy of the last income tax return filed.
Additional information or proof may be subsequently requested.
FINANCIAL ANALYSIS OF COLLECTION POTENTIAL
FOR BUSINESSES
(DOR USE ONLY)
Cash Available
(Lines 15, 16d, 18f, 19c, and 20c)
Total Cash
$
Distrainable Asset Summary
(Lines 21g, 22g, and 23g)
Total Cash
$
Monthly Income Minus Expenses
(Line 35 Minus Line 48)
Total Cash
$
Business Financial Statement- Page 6
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