Form Ia 6251b - Balance Sheet/statement Of Net Worth

IA 6251B 20 _ _

Iowa Department of Revenue

Balance Sheet/Statement of Net Worth

As of __________________

Name(s)

SSN

PART A: ASSETS

1. Total Cash .......................................................................................................... 1 . _______________________

2. Securities ........................................................................................................... 2 . _______________________

3. Pensions, IRAs, and Social Security Benefits ............................................. 3 . _______________________

4. Insurance Policies ............................................................................................ 4 . _______________________

5. Accounts Receivable ........................................................................................ 5 . _______________________

6. Inventory, including crops, livestock, other farm animals, and poultry ... 6 . _______________________

7. Real Property ..................................................................................................... 7 . _______________________

8. Machinery and Equipment ............................................................................... 8 . _______________________

9. Vehicles .............................................................................................................. 9 . _______________________

10. Other Personal Property .................................................................................. 10. _______________________

11. TOTAL ASSETS. Add lines 1-10. ................................................................... 11. _______________________

PART B: LIABILITIES

12. Current Liabilities ............................................................................................. 12. _______________________

13. Long-Term Liabilities ....................................................................................... 13. _______________________

14. Accrued Taxes .................................................................................................. 14. _______________________

15. TOTAL LIABILITIES. Add lines 12-14. .......................................................... 15. _______________________

PART C: NET WORTH

16. Total Assets less Total Liabilities. Subtract line 15 from line 11. ............ 16. _______________________

PART D: DEBT TO ASSET RATIO

17. Divide Total Liabilities (line 15) by Total Assets (line 11). ....................... 17. _______________________

41-135a (08/10/11)

Form Ia 6251b - Balance Sheet/statement Of Net Worth - 2011

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