When you are in a financial bind, the last thing you want is to add to your stress by dealing with creditors. However, if you find yourself unable to pay your bills, it is important to reach out and let your creditors know. One way to do this is by completing a debtor financial statement form. This form will provide your creditors with all of the information they need about your current financial situation. Completing this form can help you avoid collections and legal action from your creditors. If you are struggling to make ends meet, be sure to reach out to your creditors and complete a debtor financial statement form. This will provide them with all of the information they need about your current financial situation, which can help you avoid collections and legal
| Question | Answer |
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| Form Name | Debtor Financial Statement Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | Pymt, bankruptcies, III, debtor financial statement |
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 |
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(Check appropriate box) |
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Γ |
Sole Proprietor |
Γ Other (specify) |
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Γ |
Partnership |
___________________________________ |
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Γ |
Corporation |
___________________________________ |
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4 Name and title of person being interviewed |
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Employer identification number |
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6 Type of business |
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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 |
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Section I General Financial Information
8 Latest filed income tax return ► |
Form |
Tax year ended |
Net income before taxes |
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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 |
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Physical Address |
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County ………………….. |
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b |
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County ………………….. |
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c |
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County ………………….. |
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d |
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County ………………….. |
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13 Life insurance policies owned with business as beneficiary |
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Name Insured |
Company |
Policy Number |
Type |
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Face Amount |
Available Loan Value |
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Total (Enter in item 19) ……………………………………………………………………………………………………………………… ► |
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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,
b If you know of any person or |
(i) |
Who borrowed the funds? |
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organization that borrowed or otherwise |
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provided funds to pay net payrrolls: |
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(ii) |
Who supplied the funds? |
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15 Account/notes receivable (include current contract jobs, loans to stockholders, officers, partners, etc.) |
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Name |
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Address |
Amount Due |
Date Due |
Status |
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$ |
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Total (Enter in item 18)……………………………………………… ► |
$ |
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Section II Assets and Liability Analysis
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(a) |
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(b) |
(c) |
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(d) |
(e) |
(f) |
(g) |
(h) |
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Description |
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Cur. Mkt. |
Liabilities |
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Equity |
Amount of |
Name and Address of |
Date |
Date of |
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Value |
Bal. Due |
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In |
Mo. Pymt. |
Lien/Note Holder/Obligee |
Pledged |
Final Pymt. |
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Asset |
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Cash on hand |
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17 |
Bank Accounts |
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18 |
Accounts/Notes receivable |
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19 |
Life insurance loan value |
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Real |
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Property |
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(from |
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b |
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item 12) |
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21 |
Vehicles |
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a |
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(model, year, |
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and license) |
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b |
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22 |
Machinery |
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and |
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equipment |
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b |
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(specify) |
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23 |
Merchandise |
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inventory |
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(specify) |
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b |
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24 |
Other assets |
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(specify) |
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25 |
Other |
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a |
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Liabilities |
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(including |
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b |
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notes and |
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judgements) |
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c |
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g |
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h |
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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 |
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to |
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Income |
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Expenses |
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28 |
Gross receipts from sales, services, etc. |
$ |
34 Materials purchased |
$ |
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29 |
Gross rental income |
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(Number of employees………….) |
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35 |
Net wages and salaries |
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30 |
Interest, |
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36 Rent |
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31 |
Dividends |
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(Treasury use only) |
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37 |
Allowable installment payments |
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32 |
Other income (specify) |
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38 Supplies |
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39 |
Utilities/telephone |
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40 |
Gasoline/oil |
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41 |
Repairs and maintenance |
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42 |
Insurance |
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43 |
Current taxes |
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44 |
Other (specify) |
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33 |
Total income |
$ |
45 Total expenses (Treasury use only) |
$ |
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46 |
Net difference (Treasury use only) |
$ |
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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 |
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