FINANCIAL STATEMENT FOR BUSINESSES

1 DE 926C Rev. 15 (7-19) (INTERNET)Page 1 of 4 CUFINANCIAL STATEMENT FOR BUSINESSESNOTE: Complete all blocks except Dept. Use Only blocks. Write N/A (not applicable) in those blocks that do not Payroll Tax Account Number:Business Phone:Federal Employer Identification Number:Name and Address of BusinessoSole Proprietor _____oPartnership_____oCorporation State of Inc.:_____Date of Inc.: _____CA Corp. ID No. _____oOtherName, title, and phone number of person completing FINANCIAL StatementType of BusinessList Owner, Partners, Officers, Major Shareholder, and TitleEffective DateHome AddressPhone NumberLast 4 Digits of SSND river License AssetsCash on Hand$Bank Accounts: Include Savings and Loans, Credit Unions, Line of Credit, of InstitutionAddressType of AccountsAccount NumberBalance$Accounts/Notes ReceivableNameAddressAmount$Securities: Stocks, Bonds, Mutual Funds, Money Market Funds, Government Securities, or DenominationWhere LocatedValue$Dept. Use Only Section ADE 926C Rev.

2 15 (7-19) (INTERNET)Page 2 of 4 CUCurrent LiabilitiesAccounts/Taxes PayableName of Tax Agency or CreditorAddressBalance DueMo. Payment$$Dept. Use Only Section BAvailable Credit SourcesBank Charge Cards, Credit Unions, Savings and Loans, of Account or CardName and Address of FINANCIAL InstitutionAmount OwedMinimum Monthly PaymentBusiness or PersonalAvailable Credit$$$Life Insurance Policies owned with business as a beneficiaryName InsuredCompanyPolicy NumberTypeFace AmountLoan Value$$Business AssetsMachinery, Furniture, Fixtures, ValueBalance DueEquity$$$Vehicles and Heavy EquipmentMakeYearLicense NumberMarket ValueBalance DueEquity$$$ real Property AssetsOwnershipPhysical AddressCountyMarket ValueMortgage BalanceEquity$$$Dept. Use Only Section CDE 926C Rev. 15 (7-19) (INTERNET) Page 3 of 4 CUMonthly Income and Expense InformationMonthly IncomeSales$CommissionsInterestDividends Rental IncomeOther IncomeDept. Use Only Section DNecessary Monthly Operating ExpensesRent$UtilitiesWorkers Compensation InsuranceSalariesOtherDept.

3 Use Only Section EOther Monthly Operating ExpensesSuppliers$TransportationHealth InsuranceIRS Taxes (Employer portion)EDD Taxes (Employer portion)OtherDept. Use Only Section FGeneral FINANCIAL InformationOther information regarding FINANCIAL condition. If you check the YES box, please give dates and explain proceedings o Yes o NoBankruptcies o Yes o NoRepossessions o Yes o NoParticipation or beneficiary to trust, estate, etc. o Yes o NoExplanation:Anticipated increase in business income o Yes o NoIf answer is YES, give following information:SourceDate increase is expected and frequencyAmount of increase$Recent transfer of business assets of any kind o Yes o NoIf answer is YES, give following information:DescriptionReceiver/Factorin g CompanyDate of TransferFair Market ValueConsideration Received$$Address of Receiver/Factoring CompanyLicensesCA Department of Tax and Fee AdministrationBusiness License License License (Specify)CERTIFICATION Under penalty of perjury, I declare that to the best of my knowledge and belief this STATEMENT of assets, liabilities, and other information is true, correct, and Signature:Date:Page 4 of 4 CUHOW TO PREPARE THE FINANCIAL STATEMENTC omplete all requested information.

4 Write N/A (not applicable) in those areas that do not apply to your business. If the form is incomplete and/or unsigned, we will not be able to consider your request for a payment proposal. The areas explained below are those for which specific information must be provided for full disclosure. You may attach additional pages if AssetsBank Accounts Enter all accounts even if there is currently no balance. DO NOT enter bank loans. You may be requested to furnish bank statements for the last six (6) Receivable Enter requested information. Also attach a separate list describing when the receivable is due and how frequent ( , regular customer or one-time customer). Include anyone who owes the business money. Securities List all stocks, bonds, mutual funds, money market funds, government securities, etc. Include the quantity or denomination, where it is located, and the current LiabilitiesList all creditors and their addresses, the balances due, and the monthly payments, if applicable.

5 You may be requested to provide supporting Credit SourcesList only credit lines or cards by a bank, credit union, or savings and loan that have cash advance AssetsEnter all machinery, furniture, fixtures, vehicles, heavy equipment, etc. You may be requested to furnish a list detailing where the assets are located, the registered owners and lien holders, and expected payoff Property AssetsList all real estate that is owned or is being purchased. Attach a list of all owners names and type of ownership (joint tenants, tenants in common), describe the type of mortgage payments and rental income amounts, and what the property is used for (residence, vacation, office/shop, rental).Monthly Income and Expense InformationMonthly Income Enter gross sales and commissions. Include all interest, dividends, net rental income, and any other Monthly Operating Expenses Enter ordinary and necessary monthly operating expenses. Attach current profit/loss STATEMENT and balance Monthly Operating Expenses Enter the requested information.

6 When entering amounts for Internal Revenue Service and Employment Development Department taxes, only give the employer portion of the taxes due. DO NOT include amounts withheld from your employee s wages. You may be requested to provide supporting documentation for all expenses FINANCIAL InformationMark the appropriate box. For all yes answers, enter full explanation. Attach additional pages if license number for all licenses 926C Rev. 15 (7-19) (INTERNET)