Commercial Debtor Financial Statement 

Note: Complete all blocks, except shaded areas. Write “N/A” (not applicable) in those blocks that do not apply. 

2 Business phone number 

( )

1 Name and address of business 

3 (Check appropriate box) 

Γ Sole Proprietor Γ Other (specify) 

Γ Partnership ___________________________________ 

Γ Corporation ___________________________________ 

4 Name and title of person being interviewed 5 Employer identification number 6 Type of business

7 Information about owner, partners, officers, major shareholder, etc.

Name of Institution Effective 

Date 

Home Address Phone 

Number 

Social Security 

Number 

Total Shares 

of Interest 

Section I General Financial Information 

8 Latest filed income tax return ► Form Tax year ended Net income before taxes 

9 Bank accounts (List all types of accounts including payroll and general, savings, certificates of deposit, etc.)

Name of Institution Address Type of Account Account No. Balance 

Total (Enter in item 17)......................................................... ►

10 Bank credit available (Line of credit, etc.) 

Name of Institution Address Credit Limit Amount Owed Credit 

Available 

Monthly 

Payments 

Totals (Enter in items 24 or 25 as appropriate) ►

11 Location, box number, and contents of all safe deposit boxes rented or accessed. 
Section I (continued) General Financial Information 

12 Real Property 

Brief description and type of ownership Physical Address 

a

County ....................... 

b

County ....................... 

c

County ....................... 

d

County ....................... 

13 Life insurance policies owned with business as beneficiary 

Name Insured Company Policy Number Type Face Amount Available Loan Value 

Total (Enter in item 19) ....................................................................................................................................... ►

14a Additional information regarding financial condition (Court proceedings, bankruptcies filed or anticipated, transfers of assets for less than full value, changes in 

market conditions, etc. Include information regarding company participation in trusts, estates, profit-sharing plans, etc.) 

b If you know of any person or (i) Who borrowed the funds? 

organization that borrowed or otherwise 

provided funds to pay net payrrolls: (ii) Who supplied the funds? 

15 Account/notes receivable (include current contract jobs, loans to stockholders, officers, partners, etc.) 

Name Address Amount Due Date Due Status 

$ 

Total (Enter in item 18)...................................................... ►

$ 
Section II Assets and Liability Analysis 

(a) 

Description

(b) 

Cur. Mkt. 

Value 

(c) 

Liabilities

Bal. Due 

(d) 

Equity 

In 

Asset 

(e) 

Amount of 

Mo. Pymt.

(f) 

Name and Address of 

Lien/Note Holder/Obligee

(g) 

Date 

Pledged 

(h) 

Date of 

Final Pymt. 

16 Cash on hand 

17 Bank Accounts

18 Accounts/Notes receivable

19 Life insurance loan value 

a 

b 

20 Real 

Property 

 (from 

 item 12) 

c 

a 

b 

21 Vehicles 

(model, year, 

and license) 

c 

a 

b 

22 Machinery 

and 

 equipment 

 (specify) 

c 

23 Merchandise a 

inventory

(specify) b 

24 Other assets a 

(specify) 

b 

a 

b 

c 

d 

e 

f 

g 

25 Other 

Liabilities 

 (including 

 notes and 

 judgements) 

h 

26 Federal taxes owed (prior years) 

27 Total $ $ 
Section III Income and Expense Analysis 

The following information applies to income and expenses during the period 

 to 

Accounting method used 

Income Expenses 

28 Gross receipts from sales, services, etc. $ 34 Materials purchased $ 

29 Gross rental income (Number of employees.............) 

35 Net wages and salaries 

30 Interest, 36 Rent 

31 Dividends (Treasury use only)

37 Allowable installment payments 

32 Other income (specify) 38 Supplies 

39 Utilities/telephone 

40 Gasoline/oil 

41 Repairs and maintenance 

42 Insurance 

43 Current taxes 

44 Other (specify) 

33 Total income $ 45 Total expenses (Treasury use only) $ 

46 Net difference (Treasury use only) $ 

Certification: Under 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. 

47 Signature 48 Date