Form FS-6500-24 Financial Statement

FS-6500-24 (XX/202X) 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).
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):      
STATE OF INCORPORATION      	DATE OF INCORPORATION      			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
     		     	     		     
     		     	     		     
		     	     		     
		     	     		     
		     	     		     
		     	     		     
		     	     		     
		     	     		     
		     	     		     

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
PAPERWORK REDUCTION ACT STATEMENT According to the Paperwork Reduction Act of 1995, a Federal agency may not conduct or sponsor, and a person is not required to respond to, an information collection request unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection request is 0596-0082. Response to this information collection request is required to obtain or retain benefits, specifically, a special use authorization. The authority for this information collection request is the 36 CFR 251.54(e)(5)(iv) and FSH 6509.18. The time required to complete this information collection request is estimated to average 8 hours per response, including the time for reviewing instructions, searching existing data sources, collecting and maintaining the data needed, and completing and reviewing the information collection request. Send comments regarding this burden estimate or any other aspect of this information collection request, including suggestions for reducing the burden, to Forest Service Information Collections Officer, [email protected], with OMB control number 0596-0082 in the subject line. PRIVACY ACT STATEMENT Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act statement serves to inform you of the following concerning the collection of the information on this form. Purpose:  The Privacy Act of 1974 requires that the Director of Recreation, Heritage, and Volunteer Resources staff and the Director of Lands, Minerals, and Geology Management staff provide the following statements to individuals from whom they request information. Authority:  Collection of this information solicited on this form is authorized by the 36 CFR 251.54(e)(5)(iv) and FSH 6509.18. Routine Uses:  The information collected will be used by Forest Service officials to ensure that your use of National Forest System lands is administered in accordance with applicable statutes, regulations, and directives. The information collected from you is retained in the Special Uses Data System (SUDS) and is retrieved by the Forest Service create reports for the Agency’s Special Uses Program, generate bills for collection of land use fees for your authorization, monitor compliance with your special use authorization, and other matters pertaining to administration of your special use authorization. SUDS is a component of the Forest Service’s Natural Resources Manager database (NRM). A complete list of the routine uses of NRM can be found in the system of records notice associated with this form, FS-24. Disclosure:  The submission of this information is required to obtain or retain benefits, specifically, a special use authorization. NONDISCRIMINATION STATEMENT 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 the information requested in the form.  To request a copy of the complaint form, call (866) 632-9992.  Submit the 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.
U.S. GPO: 1996-720-508

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