Free Personal/Corporate Financial Statement Form - Nebraska

NEBRASKA COLLECTION AGENCY BOARD PERSONAL/CORPORATE FINANCIAL STATEMENT (This form must be completed) A completed financial statement must be completed for the owner if for a sole proprietorship OR the business entity if for a partnership, corporation, or limited liability company. The information is required so that the Board can properly evaluate the applicants' ability to qualify for such license. The Board is authorized to make all inquiries deemed necessary to verify the accuracy of the statements made herein to determine the qualification to secure such license. Name _________________________________________________________________ Address _______________________________________________________________________________________ Type of Business: Individual ___ Partnership ___ LLC ___ Corporation ___

State of Financial Condition as of ____________________, 20 ______. (Must be no more than 6 months old) ASSETS, LIABILITIES AND NET WORTH ASSETS: Current Assets: Cash on hand and in checking account Trust (client funds) Savings Certificates of Deposit Accounts Receivable (clients) Accounts Receivable (other) Notes Receivable Other - specify prepaid expenses TOTAL CURRENT ASSETS Fixed Assets: Auto Furniture, Fixtures, etc. Real Estate Other - specify ______________________________________________________ TOTAL FIXED ASSETS TOTAL ASSETS LIABILITIES & NET WORTH: Accounts Payable - Clients Accounts Payable - Other Unpaid State-Federal Taxes Other Unpaid Taxes - Interest Real Estate Mortgages payable to: ______________________________________ Notes Payable to Banks - Unsecured Notes Payable to Banks - Secured Notes Payable to Other - Specify: ______________________________________ Other debts (Lease agreements, etc. - Itemize on Separate Sheet) TOTAL LIABILITIES (omit cents) $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

NET WORTH: Capital Stock Surplus Current Earnings Treasury Stock TOTAL NET WORTH TOTAL LIABILITIES & NET WORTH NET WORTH: (if not a Corporation) Investment TOTAL LIABILITIES & NET WORTH INCOME AND OPERATING EXPENSES Average Monthly Income (past 6 months) Average Monthly Expenses (past 6months) ADDITIONAL INFORMATION List the names and addresses of your financial institutions: 1._______________________________________________________________________________________________ 2._______________________________________________________________________________________________ 3._______________________________________________________________________________________________ 4._______________________________________________________________________________________________ List the five major stockholders of the corporation OR the major investors if a sole proprietor or partnership: 1._______________________________________________________________________________________________ 2._______________________________________________________________________________________________ 3._______________________________________________________________________________________________ 4._______________________________________________________________________________________________ 5._______________________________________________________________________________________________ Please list and give a brief explanation of all Lawsuits pending or judgements entered against the applicant agency in the last 3 years (attach information if needed) Does the applicant agency have any debts, obligations, or potential liabilities of the applicant not listed elsewhere on this application _______yes _______ no Is the applicant an endorser, co-maker/signer or guarantor on an outstanding liability? ______ yes ______ no ______ no $__________ $__________ $__________ $__________ $__________ $__________

$__________ $__________ $__________ $__________

Are any assets of the applicant, including stock, pledged or assigned other than those described? ______ yes Has the applicant filed bankruptcy in the last 10 years? ______ yes ______ no

If you answered yes to any of the above questions, please attach additional pages and explain in detail, including an estimate of the liability or debt where applicable