Kentucky Statement of Financial Condition for Businesses & Instructions

 Statement of Financial Condition for Businesses & Instructions
12A639
12A639(I)
(8-04)

INSTRUCTIONS FOR COMPLETING
STATEMENT OF FINANCIAL CONDITION FOR BUSINESSES

The Statement of Financial Condition for Businesses
included in this packet provides the Department of
Revenue’s Division of Collections with credit and statistical
information that will be utilized in evaluating the financial
position of your business. Every item of the financial
statement must be completed and should reflect accurate
statements and amounts. If an item is not applicable to your
business, insert “N/A.” An incomplete Statement of
Financial Condition for Businesses will not be considered.
The Statement of Financial Condition for Businesses is
presented in four segments. Instructions have been
provided only for items requiring further clarification.
Most of the requested items are self-explanatory and need
no further interpretation.
Ownership Information (Items 1-7)
Please verify the federal employer identification number
in Item 5 and the social security number(s) of the owner(s)
in Item 7 to make sure they are correct.
Item 7 must be completed for any type of ownership
indicated in Item 3. Sole proprietorships must report the
individual owner’s name, partnerships must report all
partners’ and/or general partner’s names, and corporations
must report the names of all corporate officers. Attachments
may be used as necessary.
Section I—General Financial Information (Items 8-15)
All information recorded in this section should be verified
for accuracy. The Department of Revenue may conduct an
inquiry to substantiate this information.
If the business is a partnership, the Statement of Financial
Condition for Businesses must be completed for partnership
assets and liabilities, and a separate Statement of Financial
Condition for Individuals must be completed for each
general partner.
Item 10 should include all credit cards owned by the
business.
Item 13 should include all life insurance policies owned
by the business, such as Key-man Life Insurance.
Item 14 should report any extraordinary situations such as
recent transfers of assets, court proceedings and anticipated
changes in business income. If your business has recently
filed for bankrupcty, you must disclose the court and
bankruptcy case number.

Section II—Asset and Liability Analysis (Items 16-29)
This section resembles a balance sheet and should reflect
accurate amounts.
Item 16 should report actual cash on hand, not cash in banks
or other financial institutions.
Item 21 should report the current market value of business
vehicles as determined in an automobile “blue book” or by
other property valuation sources.
Item 25 should report all debts owed by your business.
Items 26 and 27 should report all delinquent federal and
state business taxes.
Item 28 should report totals for all entries made in each
column.
Section III—Income and Expense Analysis (Items 29-47)
This section must report all sources of income and all
business expenses directly attributable to the production of
income. Depreciation is not deemed as an out-of-pocket
expense and should not be included in the expense
summary. Additional lines have been provided for
reporting income and/or expense items not already
itemized in Section III. Each entry should be verified for
accuracy. The Department of Revenue may request
supportive documents to substantiate this information.
Item 29 must reflect an operating period of 12 months.
Item 30 must report the business’ method of accounting
(i.e., cash or accrual).
Item 36 should report total income from all income
sources listed under Items 31-35.
Item 48 should report total expenses from all liability
sources listed under Items 37-47.
Certification (Items 50-51)
Signature certifies that statements and entries contained in
the Statement of Financial Condition and/or accompanying
schedules are correct to the best knowledge and belief of the
undersigned.
Items 50 and 51 must provide signature by a duly authorized
representative, owner, partner or corporate officer along
with the applicable date signature was posted.

12A639 (8-04)

STATEMENT OF FINANCIAL CONDITION
FOR BUSINESSES

Commonwealth of Kentucky
DEPARTMENT OF REVENUE

(If additional space is needed, attach separate sheet.)
1. Name and address of business

2. Business phone number (
)
3. Type of ownership (check appropriate box)
o Sole proprietor
o Other (specify)
o Partnership
o Corporation

4. Name and title of person being interviewed

5. Federal employer
identification number

6. Type of business and
number of employees

7. Information about owner, partners, officers, major shareholders, etc.
Name and Title

Effective
Date

Home Address

Phone Number

Total Shares
or Interest

Social Security Number

SECTION I—GENERAL FINANCIAL INFORMATION (If sole proprietor, include assets and liabilities of owner.)
Form
8. Latest filed Kentucky income tax return

Tax year ended

Net income before taxes

➤

9. 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

TOTAL (Enter in Item 17)

Balance

➤

10. Bank credit available (Lines of credit, etc.)
Name of Institution

Address

TOTALS (Enter in Items 24 or 25 as appropriate)
11. Location, box number and contents of all safe deposit boxes rented or accessed

Amount
Owed

Credit
Limit

➤

Credit
Available

Monthly
Payments

Page 2
SECTION I—GENERAL FINANCIAL INFORMATION (continued)
12. Real property
Brief Description and Type of Ownership

Address (Include county and state)

a.
b.
c.
d.
13. Life insurance policies owned with business as beneficiary
Name Insured

Policy
Number

Company

Type

Face
Amount

Available Loan
Value

➤

TOTAL (Enter in Item 19)

14. 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.)

15. Accounts/notes receivable (Include loans to stockholders, officers, partners, etc.)
Name

Address

TOTAL (Enter in Item 18)

Amount Due

➤

Date Due

Status

Page 3
SECTION II—ASSET AND LIABILITY ANALYSIS

16.
17.
18.
19.
20.

Asset or Liability
Cash on hand
Bank accounts
Accounts/Notes receivable
Life insurance loan value
Real property

21. Vehicles (Model, year
and license)
22. Machinery and equipment
(Specify)
23. Merchandise inventory
(Specify)
24. Other assets (Specify)
25. Other liabilities
(Include notes
and judgments)

(c)
Cur. Mkt.
Value

(b)

(a)

Description

(d)
Liabilities
Bal. Due

(e)
Amt. of
Mo. Pymt.

a.
b.
c.
d.
a.
b.
c.
a.
b.
c.
a.
b.
a.
b.
a.
b.
c.
d.
e.
f.
g.

26. Federal taxes owed
27. State taxes owed
28. TOTAL
SECTION III—INCOME AND EXPENSE ANALYSIS
29. The following information applies to income and expenses during the

30. Accounting method used

period ________________________ to _________________________
Income
31.
32.
33.
34.
35.

Expenses

Gross receipts from sales, services, etc.
Gross rental income
Interest
Dividends
Other income (Specify)

37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.

➤

Materials purchased
Net wages and salaries
Rent
Installment payments
Supplies
Utilities/Telephone
Gasoline/Oil
Repairs and maintenance
Insurance
Current taxes
Other (Specify)

48. TOTAL
➤
49. Net difference
(Item 36 minus Item 48)
➤
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.
50. Signature
51. Date
36. TOTAL