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SHALL BE PREPARED AND SIGNED BY A LICENSED PUBLIC ACCOUNTANT (PA) OR CERTIFIED PUBLIC ACCOUNTANT (CPA) HOLDING A CURRENT PERMIT TO PRACTICE. IF LICENSED IN
ANOTHER STATE, PROVIDE COPY OF A CURRENT LICENSE. Note: Financial Statements prepared by bookkeepers and tax preparers are not acceptable.
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PRINT NAME:
SIGNATURE OF C.P.A. or P.A.:
STATE:
LICENSE NO.:
See accompanying independent accountant's report. The undersigned has no interest in the above enterprise.
TITLE (owner, president, etc.):
SIGNATURE OF APPLICANT:
I hereby certify as owner, officer, partner, manager, member or R.M.E. that the statements contained on this statement are true and correct. I certify that any misrepresentation is grounds for
refusal or subsequent revocation of license and is a misdemeanor (Sec. 710-1017, Sections 436B-19, and 444-17, Hawaii Revised Statutes).
For compiled and reviewed financial statements: This statement must be signed, whether CPA uses this form or his own.
$
TOTAL LIABILITIES AND NET WORTH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
TOTAL NET WORTH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Surplus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Capital stock (if corporation, show shares
authorized, issued-par value). . . . . . . . . . . . . . . . . . . . . . . . .
$
NET WORTH:
LIABILITIES:
Name of Applicant:
CURRENT LIABILITIES:
Notes payable (due within one year):
To banks regular . . . . . . . . . . . . . . . . .
To material men . . . . . . . . . . . . . . . . .
To other (exclusive of Equipment). . . .
TOTAL NOTES PAYABLE. . . . . . . . . . . . . . . . . . . . . . . . . .
$
$
Accounts payable:
Subcontractors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Material men. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Others. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
TOTAL ACCOUNTS PAYABLE. . . . . . . . . . . . . . . . . . . . .
$
Current maturities (long-term debt). . . . . . . . . . . . . . . . . . .
$
Accrued payrolls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Federal and state income tax. . . . . . . . . . . . . . . . . . . . . . . .
Payroll taxes (including F.I.C.A.
S.U.I. and income taxes withheld). . . . . . . . . . . . . . . . . . . . . .
Other accrued taxes, interest, etc. . . . . . . . . . . . . . . . . . . .
Encumbrances on equipment (due within 1 year). . . . .
Other Current Liabilities (specify):
$
TOTAL CURRENT LIABILITIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
LONG-TERM LIABILITIES:
Long-term debt (less portion due within one year). . . . .
Encumbrances on equipment (due after 1 year). . . . . .
$
Encumbrances on real estate. . . . . . . . . . . . . . . . . . . . . . . .
Billings in excess of cost on uncompleted contracts. .
Other long-term liabilities (specify):
TOTAL LONG-TERM LIABILITIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
TOTAL LIABILITIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
(Sole Proprietor, Corporation, Partnership, Joint Venture, LLC, LLP)
Financial Statement as of , 20
(not more than one year old) is for:
THE STATEMENT BELOW MUST BE
SIGNED BY THE APPLICANT, WHETHER
CPA USES THIS FORM OR HIS OWN.
FINANCIAL STATEMENT MUST BE
COMPILED, REVIEWED OR AUDITED
AND ACCOMPANIED BY AN
INDEPENDENT ACCOUNTANT'S
REPORT.