Form Ftb 3861a C1 - Bank And Corporation - Statement Of Financial Condition And Other Information Page 7

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State of California — Franchise Tax Board
Bank and Corporation
California Statement of Financial Condition and Other Information – Part II
To be submitted with Part I of this form or with federal Form 433-B.
1.
Statement of income — Corporation
IMPORTANT: Please furnish the information requested below (from income tax returns, as adjusted, for past 2 years and from records for current
year from January 1 to date).
a. Gross income
19
19
Jan 1 to
19
(1)
Gross sales or receipts (Subtract returns and allowances.) $
$
$
(2) Cost of goods sold
(3) Gross profit – trading or manufacturing
(4) Gross profit – from other sources
(5) Interest income
(6) Rents and royalties
(7) Gains and losses (From Schedule D.)
(8) Dividends
(9) Other (Specify)
(10) Total income
$
$
$
b. Deductions
(1) Compensation of officers
$
$
$
(2) Salaries and wages (Not deducted elsewhere.)
(3) Rents
(4) Repairs
(5) Bad Debts
(6) Rents and royalties
(7) Taxes
(8) Losses
(9) Dividends
(10) Depreciation and depletion
(11) Contributions
(12) Advertising
(13) Other (Specify)
(14)
(15) Total deductions
$
$
$
c. Net income (loss)
$
$
$
d. Nontaxable income
$
$
$
e. Unallowable deductions
$
$
$
2.
Salaries paid to principal officers and dividends distributed — Corporation
IMPORTANT: Please show salaries paid to principal officers for past 3 years and amounts distributed in dividends. If any, during and since the
taxable years covered by this offer.
a. Salaries paid to (Name and Title)
19
19
19
(1)
. President
$
$
$
(2)
. Vice President
(3)
. Treasurer
(4)
. Secretary
(5)
(6)
(7)
Total
$
$
$
b.
Year
Dividends Paid
Year
Dividends Paid
Year
Dividends Paid
(1)
$
(8)
$
(15)
$
(2)
(9)
(16)
(3)
(10)
(17)
(4)
(11)
(18)
(5)
(12)
(19)
(6)
(13)
(7)
$
(14)
$
(20) Total
$
FTB 3861A C1 (REV 11-94) PAGE 7
PAGE 13

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