FS-6500-24 Financial Statement

Special Use Administration

FS-6500-24 092020

OMB: 0596-0082

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FS-6500-24 (09/2020)

OMB No. 0596-0082


U.S. DEPARTMENT OF AGRICULTURE

FOREST SERVICE


FINANCIAL STATEMENT


AUTHORITY:

36 CFR 251.54(e)(5)(iv) and FSH 6509.18


INSTRUCTIONS: Provide your most recent fiscal year financial statement. The Forest Service may also request 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. Complete and accurate information must be provided as required in this form. Anyone who knowingly or willfully makes any false statement or representation on this form is subject to a fine, imprisonment, or both 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 OF INCORPORATION

     


  1. DATE OF INCORPORATION

     

  1. ADDRESS OF PRINCIPAL PLACE OF BUSINESS      

5. FOR PARTNERSHIPS, NAMES OR PARTNERS AND THEIR PARTNERSHIP INTERESTS:      



6. NAME, TITLE, AND ADDRESS OF CORPORATE OFFICERS AND DIRECTORS AND NUMBER OF SHARES OF STOCK OWNED BY EACH

FULL NAME

TITLE

ADDRESS, TELEPHONE NUMBERS, AND

E-MAIL ADDRESS

SHARES OWNED

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     


  1. REFERENCES (at least three, preferably from banks):


Full Name

ADDRESS, TELEPHONE NUMBERS, AND E-MAIL ADDRESS

     

     

     

     

     

     


You may submit certified financial statements in lieu of completing PARTS A through C below. However, you must complete either the certification statement in PART D.1 or PART D.2 at the bottom of the last page.


PART A. BALANCE SHEET

CURRENT YEAR

(MM/DD/YYYY)

PREVIOUS YEAR

(MM/DD/YYYY)

YEAR BEFORE

PREVIOUS YEAR

(MM/DD/YYYY)

YEAR ENDED

     

     

     

ASSETS




CURRENT ASSETS

     

     

     

CASH

     

     

     


     

     

     

RECEIVABLES

     

     

     

LESS ALLOWANCES FOR DOUBTFUL

ACCOUNTS

(     )

()

()


     

     

     

INVENTORIES (LIST MAJOR CATEGORIES)

          

     

     


          

     

     


     

     

     


     

     

     

SUPPLIES AND MISCELLANEOUS ITEMS

          

          

          

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 OF FIXED ASSETS

     

     

OTHER ASSETS

     

     

CASH DEPOSITS

     

     

SECURITIES

     

     


     

     

TOTAL OTHER ASSETS

     

     

TOTAL ASSETS

     

     



LIABLIITIES AND OWNER EQUITY

CURRENT YEAR

(MM/DD/YYYY)

PREVIOUS

YEAR

(MM/DD/YYYY)

YEAR BEFORE PREVIOUS YEAR

(MM/DD/YYYY)

CURRENT LIABILITIES

     

ACCOUNTS PAYABLE

     

ACCRUED PAYROLL

     

ACCRUED PAYROLL TAXES AND INSURANCE

     

NOTES PAYABLE

     

     

CURRENT INCOME TAXES

     

OTHER TAXES

     

     

CURRENT PORTION OF LONG-TERM DEBT

     

     

OTHER CURRENT LIABILITIES (SPECIFY)

     

     


     


     

     


     

TOTAL CURRENT LIABILITIES

     

     

     

OTHER LIABILITIES




DEFERRED INCOME TAXES

     

     

     

LOANS FROM OFFICERS OR PARTNERS

     

     

LONG-TERM DEBT LESS CURRENT PORTION OF

LONG-TERM DEBT

     

     

     

     


     

     


     

     

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

THE INCOME STATEMENT IN PART C IS CASH BASIS       ACCRUAL BASIS      .

INVENTORIES ARE LIFO      , FIFO      , COST, OR MARKET, WHICHEVER IS LOWER .


NAME, ADDRESS, TELEPHONE NUMBERS, AND E-MAIL ADDRESS OF CONTRACTORS OR SUBCONTRACTORS USED TO PREPARE THE INCOME STATEMENT IN PART C (IF ANY):      

PART C. INCOME STATEMENT

CURRENT YEAR

(MM/DD/YYYY)

PREVIOUS YEAR

(MM/DD/YYYY)

YEAR

BEFORE

PREVIOUS

YEAR

(MM/DD/YYYY)

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)




PLUS OTHER INCOME




LESS INTEREST EXPENSE




INCOME TAXES

(     )

(     )

(     )

OTHER EXPENSES

(     )

(     )

(     )

NET AMOUNT OF OTHER INCOME AND EXPENSES

(     )

(     )

(     )

NET PROFIT (LOSS) FOR YEAR:      


PART D.1. CERTIFICATION FOR CORPORATIONS, LLCs, AND PARTNERSHIPS

We, the undersigned, general officers (or members) of       [name of corporation, LLC, or partnership], swear that the above or attached financial statements are true and correct and cover all of the financial affairs of [name of corporation, LLC, or partnership] up to and including [date].


CERTIFYING OFFICIAL'S NAME AND TITLE


SIGNATURE (Sign in ink)

DATE

CERTIFYING OFFICIAL'S NAME AND TITLE


SIGNATURE (Sign in ink)

DATE


SUBSCRIBED AND SWORN TO before me this       day of      , [year].


(Affix Notary Seal)

SIGNATURE


TITLE

PART D.2. CERTIFICATION FOR INDIVIDUALS

I swear that the above or attached financial statements are true and correct.

INDIVIDUAL'S NAME AND TITLE


SIGNATURE (Sign in ink)

DATE

SUBSCRIBED AND SWORN TO before me this       day of       [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. Response to this collection of information is mandatory. The authority to collect the information is the Organic Administration Act,

16 U.S.C. 551. 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.


In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.


Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible agency or USDA’s TARGET Center at (202) 720-2600 (voice and TYY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.


To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected].


USDA is an equal opportunity provider, employer, and lender.


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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