Form M-433-Ois - Statement Of Financial Condition And Other Information Page 12
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12. Other information. You must answer all of the following questions related to the financial condition of this business. Use additional pages if necessary.
a. Does this business have any other business relationships (e.g., parent corporation, subsidiary corporation, partnership, etc.)?
Yes
No
Related Federal Identification number
Additional related Federal Identification number
b. Does anyone associated with this business (e.g., officer, stockholder, partner or employee) have an outstanding loan borrowed from this business? If
yes, also include this amount as an asset in line 3a.
Yes
No
Amount of loan
Date
Current balance
c. Are there any judgments or liens against this business? If “Yes,” include as a liability in line 3b.
Yes
No
Name of creditor
Date of judgment
Debt amount
d. Is this business a party in a lawsuit?
Yes
No
Amount of suit
Possible completion date
Subject matter of suit
e. Has this business ever filed for bankruptcy?
Yes
No
Date filed
Date discharged
Docket number
f. In the past ten years have any assets been transferred out of this business for less than their actual value?
Yes
No
Type of asset
Value at time of transfer
Consideration received
g. Do you anticipate any increase in business income in the next two years (e.g., contracts bid but not yet awarded)?
Yes
No
Reason for income increase
Amount of increase
Expected date of increase
h. Is this business the beneficiary of an estate, trust or life insurance policy?
Yes
No
Name of trust or estate
Amount to be received
Date to be received
Declaration and Signature of Applicant
Failure to disclose all information requested in this form may result in the rejection of your offer and prohibit you from having any future offer accepted.
Under the pains and penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities and other information is
true, correct and complete.
Your signature
Title
Date
Declaration and Signature of Preparer Other Than Taxpayer
Under the pains and penalties of perjury, I declare that the information given in this statement is accurate and that I have personal knowledge of the
taxpayer’s financial condition.
Preparer’s signature
Preparer’s name (print)
Date
Privacy Act Notice
Under the authority of 42 U.S.C. sec. 405(c)(2)(C)(i), and M.G.L. c. 62C, sec. 5, the Department of Revenue has the right to require an individual to furnish
his or her Social Security number on a state tax return. This information is mandatory. The Department of Revenue uses Social Security numbers for
taxpayer identification to assist in processing and keeping track of returns and in determining and collecting the proper amount of tax due. Under M.G.L.
c. 62C, sec. 40, the taxpayer’s identifying number is required to process a refund of overpaid taxes. Although tax return information is generally confiden-
tial pursuant to M.G.L. c. 62C, sec. 21, the Department of Revenue may disclose return information to other taxing authorities and those entities specified
in M.G.L. c. 62C, secs. 21, 22 or 23, and as otherwise authorized by law.
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Parent category: Financial