Form Oic 1063 – Fill Out and Use This PDF

4. Does the business engage in e-Commerce (internet sales)

Yes

No

Payment Processor (e.g., PayPal, Authorize.net, Google Checkout, etc.), Name and Address (Street, City, State, ZIP code)

Payment Processor Account Number

5a.

5b.

Credit cards accepted by the business

Type of Credit Card (e.g., Visa, MasterCard, etc.)

Merchant Account Number

Merchant Account Provider Name and Address (Street, City, State, ZIP code)

6a.

Phone

6b.

Phone

6c.

Phone

Section 2. Business Personnel and

Contacts

Partners, Officers, LLC, Members, Major Shareholders, Etc.

7a. Full Name

Social Security Number

Title

Home Telephone

Home Address

Work/Cell Phone

City

State

ZIP

Ownership Percentage & Shares or Interest

Responsible for Depositing Taxes

Yes

No

7b. Full Name

Social Security Number

Title

Home Telephone

Home Address

Work/Cell Phone

City

State

ZIP

Ownership Percentage & Shares or Interest

Responsible for Depositing Taxes

Yes

No

7c. Full Name

Social Security Number

Title

Home Telephone

Home Address

Work/Cell Phone

City

State

ZIP

Ownership Percentage & Shares or Interest

Responsible for Depositing Taxes

Yes

No

7d. Full Name

Social Security Number

Title

Home Telephone

Home Address

Work/Cell Phone

City

State

ZIP

Ownership Percentage & Shares or Interest

Responsible for Depositing Taxes

Yes

No

Business Financial Statement- (Rev. 9/12)

Page 2

8. Does the business use a Payroll Service Provider or Reporting Agent (If yes, answer the following)

Yes

No

Name and Address (Street, City, State, ZIP code)

Effective dates (mm/dd/yyyy)

9. Is the business a party to a lawsuit ( If yes, answer the following)

Yes

No

Location of Filing

Represented by

Docket/Case No.

Plaintiff

Defendant

Amount of Suit

Possible Completion Date (mm/dd/yyyy)

Subject of Suit

10. Has the business ever filed bankruptcy ( If yes, answer the following)

Yes

No

Date Filed (mm/dd/yyyy)

Date Dismissed or Discharged (mm/dd/yyyy)

Petition No.

Location

11. Do any related parties (e.g., officers, partners, employees) have outstanding amounts owed

to the business ( If yes, answer the following)

Yes

No

Name and Address (Street, City, State, ZIP code)

Date of Loan

Current balance

Payment Date

Payment Amt.

as of

$

$

12. Have any assets been transferred, in the last 10 years, from this business for less than full

value ( If yes, answer the following)

Yes

No

List Asset

Value at Time

Petition No.

Location

of transfer

$

13. Does this business have other affiliations (e.g., subsidiary or parent companies)

( If yes, answer the following)

Yes

No

Related Business Name and Address (Street, City, State, ZIP code)

Related Business EIN:

14. Any increase/decrease in income anticipated ( If yes, answer the following)

Yes

No

Explain (use attachment if needed)

How much will it increase/decrease

When will it increase/decrease

Account Balance

Type of

Full Name and Address (Street, City, State, ZIP code)

Account Number

as of

Account

of Bank, Savings & Loan, Credit Union or Financial Institution

mm/dd/yyyy

16a.

$

16b.

$

16c.

$

Business Financial Statement- (Rev. 9/12)

Page 3

Accounts/Notes Receivable. Include e-payment accounts receivable and factoring companies, and any bartering or online auction accounts.

(List all contracts separately, including contracts awarded, but not started.)

17. Is the business a Federal or State Government Contractor

Yes

No (Include Federal or State Government contracts below)

Accounts/Notes Receivable & Address

Status (e.g., age,

Date Due

Invoice Number or Federal or

Amount Due

(Street, City, State, ZIP code)

factored, other)

(mm/dd/yyyy)

State Government Contract Number

18a.

$

Contact Name:

Phone:

18b.

$

Contact Name:

Phone:

18c.

$

Contact Name:

Phone:

18d.

$

Contact Name:

Phone:

18e.

$