Form Ftb 3861a C1 - Bank And Corporation - Statement Of Financial Condition And Other Information Page 2
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8Please furnish the most recent corporate financial information. In the columns below, show the cost and fair market value of
each asset owned directly or indirectly. Also all interests in estates, trusts, and other property rights, including contingent
interests and remainders.
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Statement of assets and liabilities of ____________________
(date)
a.
Assets
Cost*
Fair market value
(1) Cash
$
(2) Cash surrender value of insurance (See item 5.)
(3) Accounts receivable (See item 7.)
(4) Notes receivable (See item 7.)
(5) Merchandise inventory (See item 8.)
(6) Real estate (See item 9.)
(7) Furniture and fixtures (See item 10.)
(8) Machinery and equipment (See item 10.)
(9) Trucks and delivery equipment (See item 11.)
(10) Automobiles (See item 11.)
(11) Securities (See item 12.)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27) Total Assets
$
$
b.
Liabilities
Amount
(1) Loans on insurance (See items 5 and 6.)
$
(2) Accounts payable
(3) Notes payable
(4) Mortgages (See item 9.)
(5) Accrued real estate taxes (See item 9.)
(6) Judgments (See item 13.)
(7) Reserves (itemized)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22) Total Liabilities
$
(*Less depreciation, if any.)
FTB 3861A C1 (REV 11-94) PAGE 2
PAGE 8
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