State of Washington
UBI number
Business Licensinge Service
PO Box 9034
Olympia, WA 98507-9034
1-800-451-7985
Collection Agency Board
Personal/Corporate Financial Statement
(This form must be completed)
A personal/corporate financial statement must be completed and submitted by the sole proprietor or the business entity
(partnership, corporation, or limited liability company). The information is required to properly evaluate the applicant’s
ability to qualify for a license. The Department is authorized to make all inquiries considered necessary to verify the
accuracy of the statements made in this application to determine if the applicant qualifies to obtain a license.
Applicant information
A
Applicant name
Applicant address Street or route, city, state, zip code
Type of business (check one):
Sole proprietor
Partnership
LLC
Corporation
State of financial condition as of _______________________ , 20 _______ (must be no more than 3 months old)
B
Assets, liabilities, and net worth (continued on page 2)
Assets
Current Assets
Cash on hand and in checking account
$
Trust (client funds)
$
Savings
$
Certificates of deposit
$
Accounts receivable (clients)
$
Accounts receivable (other)
$
Notes receivable
$
Other - specify prepaid expenses
$
Total current assets
$
Fixed assets
Auto
$
Furniture, fixtures, etc.
$
Real estate
$
Other - specify: _______________________
$
Total fixed assets
$
Total assets
$
Liabilities
Accounts payable (clients)
$
Accounts payable (other)
$
Unpaid state and federal taxes
$
Other unpaid taxes - interest
$
Real estate mortgages - payable to:________________
$
Notes payable to banks - unsecured
$
Notes payable to banks - secured
$
Notes payable to other - specify: ___________________
$
Other debts (lease agreements, etc., itemize on
separate sheet)
$
Total liabilities
$
BLS-700-331 (5/20/11) Page 1 of 2
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