Form 12a639 - Statement Of Fimamcial Condition For Businesses - 2004
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312A639 (8-04)
STATEMENT OF FINANCIAL CONDITION
Commonwealth of Kentucky
FOR BUSINESSES
DEPARTMENT OF REVENUE
(If additional space is needed, attach separate sheet.)
1. Name and address of business
2. Business phone number (
)
3. Type of ownership (check appropriate box)
o Sole proprietor
o Other (specify)
o Partnership
o Corporation
4. Name and title of person being interviewed
5. Federal employer
6. Type of business and
identification number
number of employees
7. Information about owner, partners, officers, major shareholders, etc.
Effective
Total Shares
Name and Title
Home Address
Phone Number
Social Security Number
or Interest
Date
SECTION I—GENERAL FINANCIAL INFORMATION (If sole proprietor, include assets and liabilities of owner.)
Form
Tax year ended
Net income before taxes
8. Latest filed Kentucky income tax return
9. Bank accounts (List all types of accounts including payroll and general, savings, certificates of deposit, etc.)
Name of Institution
Address
Type of Account
Account Number
Balance
TOTAL (Enter in Item 17)
10. Bank credit available (Lines of credit, etc.)
Amount
Credit
Credit
Monthly
Name of Institution
Address
Owed
Limit
Available
Payments
TOTALS (Enter in Items 24 or 25 as appropriate)
11. Location, box number and contents of all safe deposit boxes rented or accessed
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