Form Ppa-Bus - Statement Of Financial Condition For Businesses

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PPA-BUS
Page 1
STATEMENT OF FINANCIAL CONDITION
State of Tennessee
(If additional space is needed,
Department of Revenue
FOR BUSINESSES
attach separate sheet)
SECTION I - BUSINESS IDENTIFICATION
1. Business Name and Address
2. Mailing Address (If Different From Street Address)
County
4. Daytime Phone Number
5. Number of Employees
3. Type of Business
6. Type of Ownership
7. Tennessee Entity ID:
[ ] Proprietorship
[ ] Partnership
[ ] Corporation
[ ] Other (Specify)
9. Ending Date of Business (If Closed)
8. Beginning Date of Business
Form
Tax Year Ended
Net Income
10. Last Franchise Excise Return Filed
$
11. Information About Owner, Partners, Officers, Major Shareholders, etc.
Social Security
Effective
Monthly
Total Shares
Name
Title
Salary or Wages
or Interest
Number
Date
$
SECTION II - ASSETS
12. Cash On Hand
TOTAL (Enter also on Page 3, Item 24-A)
$
13. Bank Accounts (General Operating, Payroll, Savings, Certificate of Deposit, etc.)
Name of Institution
Balance
Type of Account
Account Number
$
$
TOTAL (Enter also on Page 3, Item 24-B)
14. Bank Credit Available (Line of Credit, Credit Cards, etc.)
Credit
Credit
Amount
Name of Institution
Account Number
Limit
Owed
Available
$
$
$
$
TOTAL (Enter also on Page 3, Item 24-C)

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