FS-6500-24 Financial Statement

USDA Forest Service FS-6500-24 (03/06) - Page 24

FINANCIAL STATEMENT (Ref. 36 CFR 223.7(e), 36 CFR 251.54(e)(2), Federal Acquisition Regulation 48 CFR 9.104-1.) INSTRUCTIONS: Forest Service (FS) requires the respondent to provide the most recent fiscal year financial statement. FS may also request the respondent to provide two additional years of financial data, on a case by case basis. If more space is needed to fully answer any item below, attach additional sheets.
NAME OF CORPORATION, PARTNERSHIP, OR PROPRIETORSHIP (include any names the organization/firm operated under during past three years and specify the year operated for each name):      
STATE INCORPORATED      	3. DATE INCORPORATED      				4. ADDRESS OF PRINCIPAL PLACE OF BUSINESS (with ZIP CODE)      
5. IF PARTNERSHIP, NAMES OR PARTNERS, AND THEIR PARTNERSHIP INTERESTS      
6. NAMES, TITLES, AND ADDRESSES OF CORPORATE OFFICERS AND DIRECTORS, WITH NUMBER OF SHARES OF STOCK OWNED BY EACH
FULL NAME		TITLE		ADDRESS (Number, Street, City, State, and ZIP CODE)		SHARES OWNED
     		     		     		     
     		     		     		     
		     		     		     
		     		     		     
		     		     		     
		     		     		     
		     		     		     
		     		     		     
		     		     		     
		     		     		     
		     		     		     
REFERENCES (At least three should be given, preferable banks):
Full Name			ADDRESS (Number, Street, City, State, and ZIP CODE)
     			     
     			     
     			     
NOTE: Respondents may submit certified financial statements in lieu of answering PARTS A through C on the next pages. However, respondents must complete either certification statement PART D (1) or PART D (2) at the bottom of the last page.

PART A. BALANCE SHEET
	CURRENT YEAR (MM/DD/YYYY)	PAST YEAR (MM/DD/YYYY)	THIRD YEAR (MM/DD/YYYY)
YEAR ENDED	     	     	     
ASSETS
CURRENT ASSETS:	     	     	     
CASH	     	     	     
RECEIVABLES-TRADE	     	     	     
LESS ALLOWANCES FOR DOUBTFUL ACCOUNTS	<     >	<>	<       >
	     	     	     
INVENTORIES (LIST MAJOR CATEGORIES):	     	     	     
     	     	     	     
     	     	     	     
	     	     	     
SUPPLIES AND MISCELLANEOUS	     	     	     
MARKETABLE SECURITIES	     	     	     
	     
PREPAID EXPENSES
SUPPLIES INVENTORY
OTHER CURRENT ASSETS:
     
     
	     		     
TOTAL CURRENT ASSETS	     	     
FIXED ASSETS:		     
LAND		     
BUILDINGS		     
MACHINERY AND EQUIPMENT		     
PLANT		     
LEASEHOLD IMPROVEMENTS		     
OTHER      		     
		     	     
LESS ALLOWANCE FOR DEPRECIATION	<     >	<>	<       >
BOOK VALUE-FIXED ASSETS	     	     
OTHER ASSETS:	     	     
DEPOSITS-CASH	     	     
DEPOSITS-SECURITIES	     	     
	     	     
TOTAL-OTHER ASSETS	     	     
TOTAL ASSETS	     	     

LIABLIITIES AND OWNER EQUITY			CURRENT YEAR		PAST YEAR	THIRD YEAR
CURRENT LIABILITIES:			     
ACCOUNTS PAYABLE-TRADE	     
ACCRUED PAYROLL	     
ACCRUED PAYROLL TAXES AND INSURANCE	     
NOTES PAYABLE	     			     
INCOME TAXES-CURRENT	     
OTHER TAXES	     			     
CURRENT PORTION OF LONG-TERM DEBT	     			     
OTHER CURRENT LIABILITIES (SPECIFY):	     			     
     	     
     	     			     
     	     
TOTAL CURRENT LIABILITIES	     	     		     
OTHER LIABILITIES:
DEFERRED INCOME TAXES	     	     		     
LOANS FROM OFFICERS/PARTNERS	     			     
LONG-TERM OBLIGATIONS-LESS CURRENT AMOUNT	     			     
     	     			     
     	     			     
     	     			     
TOTAL OTHER LIABILITIES	     			     
TOTAL LIABILITIES	     	     		     
OWNER EQUITY:	     	     		     
CAPITAL STOCK OUTSTANDING	     	     		     
RETAINED EARNINGS (DEFICIT)	     	     		     
	     	     		     
PARTNERS' INVESTMENT (DEFICIT)	     	     		     
     	     	     		     
     	     	     		     
TOTAL OWNER EQUITY	     	     		     
TOTAL LIABILITIES AND OWNER EQUITY	     	     		     

PART B. SUPPLEMENTAL DATA
THIS STATEMENT IS ON THE-CASH BASIS       ACCRUAL BASIS      
INVENTORIES ARE-LIFO       FIFO       COST OR MARKET WHICHEVER IS LOWER
NAMES OF CONTRACTORS OR SUB-CONTRACTORS USED (IF ANY):      
PART C. INCOME STATEMENT CURRENT YEAR PAST YEAR THIRD YEAR
GROSS SALES
LESS-RETURNS AND ALLOWANCES	<      >	<      >	<      >
NET SALES
LESS-COST OF GOODS SOLD	<      >	<      >	<      >
GROSS PROFIT ON SALES
LESS-SELLING EXPENSE	<      >	<      >	<      >
NET PROFIT (LOSS) ON SALES	     	     	     
GENERAL EXPENSE:
OFFICERS SALERIES	     	     	     
LEGAL AND OTHER PROFESSIONAL EXPENSE	     	     	     
OFFICE EXPENSE	     	     	     
TOTAL GENERAL EXPENSE	     	     	     
NET OPERATING PROFIT (LOSS)
ADD-OTHER INCOME	     	     	     
LESS-INTEREST EXPENSE
INCOME TAXES	<      >	<      >	<      >
OTHER EXPENSE	<      >	<      >	<      >
NET AMOUNT OF OTHER INCOME AND EXPENSE	<      >	<      >	<      >
NET PROFIT (LOSS) FOR YEAR	     	     	     
NOTE: Offers must set forth full, accurate, and complete information as required in this Financial Statement (including any attachments). The penalty for making false statements in this Financial Statement is prescribed in 18 U.S.C. 1001.

PART D (1): CERTIFICATION FOR CORPORATIONS OR PARTNERSHIPS We, the undersigned, general officers (or members) of       (insert name of corporation or partnership) being severally sworn, each declares that the above or attached financial statements are true and correct, and that it covers all of the financial affairs of said company (or) firm up to and including the date of       (Month day, year)
CERTIFYING OFFICIAL'S NAME AND TITLE      	SIGNATURE (Sign in ink)	DATE
CERTIFYING OFFICIAL'S NAME AND TITLE      	SIGNATURE (Sign in ink)	DATE
SWORN TO AND SUBSCRIBED before me this       day of       (Month/Year)		(Affix Notary Seal)
SIGNATURE	TITLE
PART D (2). CERTIFICATION FOR INDIVIDUALS I swear (or affirm) that the above or attached financial statements are true and correct to the best of my knowledge.
INDIVIDUAL'S NAME AND TITLE      	SIGNATURE (Sign in ink)	DATE
SWORN TO AND SUBSCRIBED before me this       day of       (Month/Year)		(Affix Notary Seal)
SIGNATURE	TITLE
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0082. The time required to complete this information collection is estimated to average 8 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 975-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer. The Privacy Act of 1974 (5 U.S.C. 552a) and the Freedom of Information Act (5 U.S.C. 552) govern the confidentiality to be provided for information received by the Forest Service.
�U.S. GPO: 1996-720-508