Personal/corporate Financial Statement
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2NEBRASKA COLLECTION AGENCY BOARD
PERSONAL/CORPORATE FINANCIAL STATEMENT
(This form must be completed)
A completed financial statement must be completed for the owner if for a sole proprietorship OR the business entity if for a
partnership, corporation, or limited liability company. The information is required so that the Board can properly evaluate the
applicants’ ability to qualify for such license. The Board is authorized to make all inquiries deemed necessary to verify the
accuracy of the statements made herein to determine the qualification to secure such license.
The following is being submitted by ________________________________________(name and title) as a true and accurate
statement of financial condition of ________________________________________(name of applicant) on __________, 20____.
(Must be no more than 6 months old)
Type of Business:
Individual ___
Partnership ___
LLC ___
Corporation ___
ASSETS, LIABILITIES AND NET WORTH
ASSETS:
(omit cents)
Current Assets:
Cash on hand
$__________
Cash in Bank (Itemize)
(a) Trust Account (Client Funds)
$__________
$__________
(b) Operating Account
$__________
(c) Other Bank Accounts
Accounts Receivable
$__________
a) Clients
$__________
b) Other
Notes Receivable
$__________
Other (Itemize)
$__________
__________$__________
__________$__________
TOTAL CURRENT ASSETS
$__________
Fixed Assets:
Furniture, Fixtures, etc.
$__________
Real Estate
$__________
Other (Itemize)
$__________
__________$__________
__________$__________
TOTAL FIXED ASSETS
$__________
TOTAL ASSETS
$__________
LIABILITIES & NET WORTH:
Accounts Payable
a) Clients
$__________
b) Other
$__________
Taxes Payable (Itemize)
$__________
__________$__________
__________$__________
__________$__________
Real Estate Mortgages payable to:
______________________________________
$__________
Notes Payable to Banks
$__________
a) Secured
secured
$__________
b) Un
Notes Payable to Other - Specify:
______________________________________
$__________
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