Financial Statement For Businesses Page 3

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Monthly Income and Expense Information
Monthly Income
Necessary Monthly Operating Expenses
Sales
$
Rent
$
Commissions
Utilities
Interest
Workers’ Compensation Insurance
Dividends
Salaries
Rental Income
Other
Other Income
Dept. Use Only
Section D
Dept. Use Only
Section E
Other Monthly Operating Expenses
Suppliers
$
Transportation
Health Insurance
IRS Taxes (Employer portion)
EDD Taxes (Employer portion)
Other
Dept. Use Only
Section F
General Financial Information
Other information regarding financial condition. If you check the YES box, please give dates and explain below.
Court proceedings
Yes
No
Bankruptcies
Yes
No
Repossessions
Yes
No
Participation or beneficiary to trust, estate, etc.
Yes
No
Explanation:
Anticipated increase in business income
Yes
No
If answer is YES, give following information:
Source
Date increase is expected and frequency
Amount of increase
$
Recent transfer of business assets of any kind
Yes
No
If answer is YES, give following information:
Description
Receiver
Date of Transfer
Fair Market Value
Consideration Received
$
$
Licenses
Board of Equalization
Business License No.
Contractor License No.
Liquor License No.
Other (Specify)
CERTIFICATION Under penalty 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:
Date:
DE 926C Rev. 13 (5-15) (INTERNET)
Page 3 of 4

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