FS-6500-24 Financial Statement

Special Use Administration

FS_6500_24 v07-2012

Special Use Administration - Individuals - Forest Service

OMB: 0596-0082

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USDA Forest Service FS-6500-24 (V. 07/2012)

OMB No. 0596-0082


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. False or fraudulent financial reporting on this form is subject to a fine or imprisonment under 18 U.S.C. 1001(a).


  1. NAME OF CORPORATION, LIMITED LIABILITY COMPANY (LLC.), PARTNERSHIP, OR PROPRIETORSHIP (include any names the organization/firm operated under during past three years and specify the year operated for each name):      





  1. 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

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

  1. 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 PAST YEAR THIRD YEAR

(MO/DA/YR) (MO/DA/YR) (MO/DA/YR)

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, LIMITED LIABILITY COMPANIES OR PARTNERSHIPS

We, the undersigned, general officers (or members) of      

(Name of corporation, LLC. 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       2     .


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


Burden Statement

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.


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To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410, or call toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or at (866) 377-8642 (relay voice).  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


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