California Form 3555 - Request For Tax Clearance Certificate - Corporations

California Form 3555 - Request For Tax Clearance Certificate - Corporations - 2003 Page 3

FINANCIAL STATEMENT FOR INDIVIDUAL OR OTHER ENTITY

Corporation name

Corporation number

Statement of Assets and Liabilities

Present

Liabilities

Equity in

Item

value (A)

balance due (B)

asset

Cash

Bank accounts

Stocks and bonds

Cash or loan value of insurance

Household furniture

Real property

Vehicles

Other assets (describe)

Federal taxes outstanding

Loans

Other (include judgements)

Net assets

(Total column A less total column B)

General Information (Please attach additional schedules if necessary.)

Net annual income

Source (name of business or employer)

Banks and savings and loan accounts (names and addresses)

Description and license number of each vehicle

Stocks and bonds (name of company, number of shares, etc.)

Real property (brief descriptions and locations)

I certify that the information above is correct to the best of my knowledge.

Assumer’s name (print) _____________________________________________________________________________________________________

Assumer’s address ____________________________________________________________ Phone number (

) _______________________

Assumer’s signature __________________________________________________________________________ Date _______________________

FTB 3555 C1 (REV 11-2003) PAGE 3

California Form 3555 - Request For Tax Clearance Certificate - Corporations - 2003 Page 3