Debtor Financial Statement Form PDF Details

The Debtor Financial Statement form serves as a comprehensive document designed to encapsulate the financial health and operations of a commercial entity. It requires detailed inputs ranging from basic identification information, such as the name and address of the business and the employer identification number, to more intricate financial data, including but not limited to, accounts receivable, bank accounts, credit availability, and details of real property owned. The form delineates between various types of business structures like sole proprietorships, partnerships, and corporations, ensuring specificity in its application. Additionally, it delves into assets and liability analysis, providing space for the listing of assets such as cash on hand, life insurance policies, real property, and vehicles, alongside corresponding liabilities and equities. A section dedicated to income and expense analysis further extends the form’s utility by capturing the essence of the business’s operational turnover and expenditures over a specified period. It culminates in a certification that demands the truthfulness and accuracy of the information provided under the penalties of perjury. This form stands not just as a financial snapshot but as a critical tool in assessing a business's viability, risks, and overall fiscal stewardship, facilitating decision-making processes for creditors or regulatory bodies.

QuestionAnswer
Form NameDebtor Financial Statement Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesPymt, bankruptcies, III, debtor financial statement

Form Preview Example

Commercial Debtor Financial Statement

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

1 Name and address of business

2

Business phone number

 

 

 

(

 

)

 

 

 

 

 

 

 

 

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

Total Shares

Number

of Interest

 

 

Section I General Financial Information

8 Latest filed income tax return

Form

Tax year ended

Net income before taxes

 

 

 

 

 

 

 

9Bank 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)…………………………………………………

10Bank 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)

 

 

(b)

(c)

 

(d)

(e)

(f)

(g)

(h)

 

 

Description

 

Cur. Mkt.

Liabilities

 

Equity

Amount of

Name and Address of

Date

Date of

 

 

 

 

 

 

Value

Bal. Due

 

In

Mo. Pymt.

Lien/Note Holder/Obligee

Pledged

Final Pymt.

 

 

 

 

 

 

 

 

Asset

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16

Cash on hand

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17

Bank Accounts

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18

Accounts/Notes receivable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19

Life insurance loan value

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20

Real

 

a

 

 

 

 

 

 

 

 

 

 

 

Property

 

 

 

 

 

 

 

 

 

 

 

 

 

(from

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b

 

 

 

 

 

 

 

 

 

 

 

item 12)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21

Vehicles

 

a

 

 

 

 

 

 

 

 

 

 

 

(model, year,

 

 

 

 

 

 

 

 

 

 

 

 

 

and license)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22

Machinery

 

a

 

 

 

 

 

 

 

 

 

 

 

and

 

 

 

 

 

 

 

 

 

 

 

 

 

equipment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b

 

 

 

 

 

 

 

 

 

 

 

(specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23

Merchandise

 

a

 

 

 

 

 

 

 

 

 

 

 

inventory

 

 

 

 

 

 

 

 

 

 

 

 

 

(specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24

Other assets

 

a

 

 

 

 

 

 

 

 

 

 

 

(specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25

Other

 

a

 

 

 

 

 

 

 

 

 

 

 

Liabilities

 

 

 

 

 

 

 

 

 

 

 

 

 

(including

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b

 

 

 

 

 

 

 

 

 

 

 

notes and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

judgements)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

g

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

Accounting method used

 

 

to

 

 

 

 

 

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