Form Bls-700-331 - Collection Agency Board Personal/corporate Financial Statement - State Of Washington Page 2

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B
Assets, liabilties, and net worth (continued from page 1)
Corporation net worth (if you are not a corporation, skip this section and fill out the non-corporation net worth section
below)
Capital stock
$
Surplus
$
Current earnings
$
Treasury stock
$
Total net worth
$
Total liabilities and
net worth
$
Non-corporation net worth (complete this section only if you are a sole proprietorship, LLC or partnership)
Investment
$
Total net worth
$
Total liabilities and
net worth
$
C
Income and operating expenses
Average monthly income (past 3 months)
$
Average monthly expenses (past 3 months)
$
D
Additional information
List the five major stockholders of the corporation OR the major investors if a sole proprietorship or
partnership.
1.
2.
3.
4.
5.
Please list and give a brief explanation of all lawsuits pending or judgements entered against the applicant agency in
the last 3 years (attach information if needed).
Does the applicant agency have any debts, obligations, or potential liabilities of the applicant not
listed elsewhere on this application? ...................................................................................................
Yes
No
Is the applicant an endorser, co-maker/signer or guarantor on an outstanding liability? .....................
Yes
No
Are any assets of the applicant, including stock, pledged or assigned other than those described? ..
Yes
No
If you answered yes to any of the above questions, please attach additional pages and explain in detail,
including an estimate of the liability or debt where applicable.
For assistance or to request this document in an alternate format, visit or call 1-800-451-7985. Teletype (TTY) users may call 360-705-6718.
BLS-700-331 (5/20/11) Page 2 of 2

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