New Alcoholic Beverage Retailers Permit Application Page 10
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13SUMMARY FINANCIAL STATEMENT
ALCOHOLIC BEVERAGE CONTROL
PERMIT DEPARTMENT
P.O. BOX 540, MADISON, MS. 39130-0540
I.
Name _______________________________________________
(last)
(first)
(middle)/(maiden)
II.
Name of business ______________________________________
III.
Financial statement is: _ personal _ partnership _ corporation
IV.
List checking, savings, and/or loan institution references. Continue
on separate page if needed.
Checking: ____________________________________________
(institution name)
(account number)
Savings: _____________________________________________
(institution name)
(account number)
Loan: ________________________________________________
(institution name)
(account number)
V.
List each asset, tangible or intangible, below. These amounts are
accurate as of (insert date) ______________________ , ______ .
Current Assets
Cash on hand .....................................
$_______________
Cash on Deposit .................................
$_______________
Accounts & Notes Receivable ............. $_______________
Investments
Stocks and Bonds ..............................
$_______________
Business Investment ........................... $_______________
Fixed Assets
Real estate ........................................
$_______________
Other .................................................
$_______________
Total Assets ................... $_______________
VI.
List each liability below. These amounts are accurate as of (insert
date) ___________________ , _______ .
Current Liabilities (debts due within one year)
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