Free TC-803 - Utah

Utah State Tax Commission
210 North 1950 West - Salt Lake City - Utah 84134 - Telephone (801) 297-2200

Collection Information For Businesses
1. Name and Address of Business 2. Business Telephone Number

TC-803 Rev. 1/96

3. (Check appropriate box) Sole Proprietor Partnership Corporation 4. Name and Title of Person Interviewed 5. Account Number: Sales Withholding Other 7. Information about Owner, Partners, Officers, etc. Name and Title Effective Date Home Address Telephone Number Social Security Number Total Shares Other (specify)

6. Type of Business

Section One: General Financial Information
8. Latest Filed Income Tax Return Form Tax Year Ended Net Income Before Taxes

Bank Accounts (List all types of accounts including payroll and general, savings, certificates of deposit, etc.) Name of Institution Address Type of Account Account Number $ Balance

9. Total (Enter in item 16) Bank Credit Available (Lines of credit, etc.) Credit Limit $ $ Amount Owed $ Credit Available $ Monthly Payment

Name of Institution

Address

10. Totals (Enter in Items 23 or 24 as appropriate)
FORM TC803A 1/96

SECTION I, General Financial Information - Continued 11. Real Estate: (Enter values, balance due, equity in asset, and monthly payment in item 19.) Brief Description and Type of Ownership a. Address (Include County and State)

b.

c.

12. Life Insurance Policies Owned with Business as Beneficiary Name Insured Company Policy Number Type $ Face Amount $ Accumulative Cash Value

12. Total (Enter in Item 18) 13. Additional Information Regarding Financial Condition (court proceedings, bankruptcies filed or anticipated, transfers of assets for less than full value, changes in market conditions, etc.; including information regarding company participation in trusts, estates, profit-sharing plans, etc.)

14.

Accounts/Notes Receivable (Include loans to stockholders, officers, partners, etc.) Name Address $ Amount Due Date Due Status

14, Total (Enter in Item 17)

$
1/96

FORM TC803B For additional information, you may access the Tax Commission's World Wide Home Page at: http://www.tax.ex.state.ut.us If you need an accommodation under the Americans with Disabilities Act, contact the Tax Commission at (801) 297-3811 or Telecommunication Device for the Deaf (801) 297-3819. Please allow three working days for a response.

Section Two: Asset and Liability Analysis
Description (a) 15. Cash 16. Bank Accounts (from item 9) 17. Accounts/Notes Receivable (from item 14) Life Insurance Loan Value 18. (from item 12) a 19. Real Property b c d $ $ $ Current Market Value (b) Liabilities Balance Due (c) $ Equity in Asset (d) Amount of Monthly Payment (e) Name and Address of Lien/Note Holder/Obligee (f) Date Pledged (g) Date of Final Payment (h)

20. Vehicles Model, Year, License

21. Machines and Equipment (Specify)

22. Merchandise Inventory (Specify)

23. Other Assets (Specify) (from item 10)

24. Other Liabilities (included notes and judgments) (from item 10)

25. Federal Taxes Owed 26. State Taxes Owed 27. Total

FORM TC803C 1/96

Section Three: Monthly Income and Expense Analysis
The following information applies to income and expenses during the period _________ to __________
Income 28. Gross receipts from sales, services, etc. 29. Gross rental income 30. Interest 31. Dividends 32. Other income (specify) $ 34. Materials purchased 35. Net wages and salaries 36. Rent 37. Installment payments 38. Supplies 39. Utilities/Telephone 40. Gasoline/Oil 41. Repairs and maintenance 42. Insurance 43. Current taxes 44. Other (specify) Expenses Accounting method used: (cash or accrual)

$

33. TOTAL

$

45. TOTAL 46. NET DIFFERENCE

$ $

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. Signature: Date:

FORM TC803D 1/96