BUSINESS FINANCIAL STATEMENT
Name of Business: _____________________________ License Number: ___________________
Prepared By: _____________________________ Title (Position): ___________________
Sole Proprietor: ________ Partnership: _________ Corporation: ___________
Statement of Financial Condition as of: ____________________, 20_____
ASSETS
LIABILITIES AND NET WORTH
CURRENT ASSETS:
CURRENT LIABILITIES:
Cash on Premises
Accounts Payable (Schedule 6)
Cash in Banks (Schedule 1a)
Accrued Interest on Borrowings
Certificates of Deposit (Schedule 1b)
Notes Payable – Current Portion
Stocks, Bonds & Other Marketable
Assets (Schedule 2)
Accrued Taxes on Real Estate (Schedule
7)
Accounts, Loans & Notes Receivable
(Schedule 3)
Accrued Taxes/Other (Schedule 7)
Advances to Employees
Other Current Payables (Itemize)
Prepaid Expenses (Schedule 4)
Other Current Assets (Itemize)
TOTAL CURRENT LIABILITIES
TOTAL CURRENT ASSETS
LONG TERM LIABILITIES:
Notes Payable (Itemize)
FIXED ASSETS:
Real Estate & Buildings (Schedule 5)
Less: Accumulated Depreciation
Furniture, Equipment & Vehicles
Notes Payable on Real Estate (Schedule
5)
Less: Accumulated Depreciation
Other Long Term Liabilities (Itemize)
Other Fixed Assets (Itemize)
Other Long Term Assets (Itemize if over
5%of total)
TOTAL LONG TERM LIABILITIES
NET WORTH OR STOCKHOLDER’S
EQUITY
(Schedule 8)
TOTAL ASSETS
TOTAL LIABILITIES & NET
WORTH
Assets pledged or hypothecated valued at $_____________ are pledged to secure notes or obligations aggregating
$________________. I have additionally endorsed, guaranteed or am contingently liable for debts or others amounting to
$________________.
Texas Department of Banking
SCHEDULES
Schedule 1. (a) Cash in Financial Institutions.
Name of Financial Institution and Address
Account in Name Of
Type of
Account
Account
Number
Balance
TOTAL
Schedule 1. (b) Certificates of Deposit.
Name of Financial Institution and Address
Account in
Name Of
If Pledged,
State to Whom
Maturity Date
Account Number
Balance
TOTAL
Schedule 2. Stocks, Bonds & Other Marketable Assets.
Face Value Bonds
No. Stock Shares
Description
of Security
Registered in
Name of
Cost
Income Received
Last Year
If Pledged,
State to Whom
Present
Market
Value
TOTAL
Schedule 3. Accounts, Loans & Notes Receivable.
Name and Address of Debtor
Age of
Debt
Description or
Nature of Debt
Description of
Security Held
Date Payment
Expected
Amount
Owing
TOTAL
Texas Department of Banking
Schedule 4. Prepaid Expenses.
Type of Prepaid
To Whom Paid
Expiration Date
Original Amount
Current Balance
TOTAL
Schedule 5. Real Estate & Buildings.
Location or Street No.
& Description
Mortgages
or Liens
Due Dates &
Payment Amount
Unpaid Taxes
Cost
Present Market
Value
Year
Amt.
TOTAL
Schedule 6. Accounts Payable.
Nature of Account
Payable To
When Due
Amount Due
TOTAL
Schedule 7. Accrued Taxes.
Type of Tax
Payable To
When Due
Amount Due
TOTAL
Texas Department of Banking
Schedule 8. Net Worth or Stockholders’ Equity.
Type
Amount
Common Stock (____Shares)
Preferred Stock
Additional Paid-In Capital
Retained Earnings
TOTAL
Texas Department of Banking
STATEMENT OF INCOME AND EXPENSES
For The Period _______________,20___ to ________________, 20___
INCOME:
________________________________ ____________________________
________________________________ ____________________________
Other Income (Itemize) ____________________________
________________________________ ____________________________
________________________________ ____________________________
TOTAL INCOME __________________(+)
EXPENSES
Advertising ____________________________
Cash (Over) Short ____________________________
Depreciation & Amortization ____________________________
Equipment Rental ____________________________
Insurance ____________________________
Interest & Bank Charges ____________________________
Legal, Audit, Bookkeeping ____________________________
Office Supplies ____________________________
Rent ____________________________
Salaries ____________________________
Security & Janitor ____________________________
Taxes & Payroll ____________________________
Utilities & Telephone ____________________________
Vehicle Expense ____________________________
Other Expenses (Itemize)
_______________________________ ____________________________
_______________________________ ____________________________
_______________________________ ____________________________
TOTAL EXPENSES __________________(+)
NET OPERATING INCOME (LOSS) __________________
OTHER INCOME (EXPENSES)
(Itemize)
_______________________________ _____________________________
_______________________________ _____________________________
_______________________________ _____________________________
TOTAL OTHER INCOME (EXPENSES) __________________(+)
INCOME BEFORE TAXES __________________
INCOME TAXES __________________(-)
NET INCOME (LOSS) __________________
Texas Department of Banking
I hereby certify under penalty of perjury that the information contained in this confidential
financial report, including supplemental schedules, has been carefully examined by me and is
correct and compete and further acknowledge that there are no misrepresentation or omissions of
material facts.
Dated and signed this _____ day of ___________________, 20____.
________________________________________
(Signature)
________________________________________
(Typed or Printed Name)
________________________________________
(Title)
Texas Department of Banking
