Statement Of Financial Affairs Template Page 10
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22 . Former partners, officers, directors and shareholders
a.
If the debtor is a partnership, list each member who withdrew from the partnership within one year immediately
None
preceding the commencement of this case.
NAME
ADDRESS
DATE OF WITHDRAWAL
___________________________________________________________________________________________________
b.
If the debtor is a corporation, list all officers or directors whose relationship with the corporation terminated
None
within one year immediately preceding the commencement of this case.
NAME AND ADDRESS
TITLE
DATE OF TERMINATION
___________________________________________________________________________________________________
23 . Withdrawals from a partnership or distributions by a corporation
If the debtor is a partnership or corporation, list all withdrawals or distributions credited or given to an insider,
None
including compensation in any form, bonuses, loans, stock redemptions, options exercised and any other perquisite
during one year immediately preceding the commencement of this case.
NAME & ADDRESS
AMOUNT OF MONEY
OF RECIPIENT,
DATE AND PURPOSE
OR DESCRIPTION
RELATIONSHIP TO DEBTOR
OF WITHDRAWAL
AND VALUE OF PROPERTY
___________________________________________________________________
24. Tax Consolidation Group.
If the debtor is a corporation, list the name and federal taxpayer-identification number of the parent corporation of any
None
consolidated group for tax purposes of which the debtor has been a member at any time within six years
immediately preceding the commencement of the case.
NAME OF PARENT CORPORATION
TAXPAYER-IDENTIFICATION NUMBER (EIN)
_____________________________________________________________________________________________________
25. Pension Funds.
If the debtor is not an individual, list the name and federal taxpayer-identification number of any pension fund to
None
which the debtor, as an employer, has been responsible for contributing at any time within six years immediately
preceding the commencement of the case.
NAME OF PENSION FUND
TAXPAYER-IDENTIFICATION NUMBER (EIN)
* * * * * *
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