CHAPTER 13 BUSINESS REPORT Debtor(s) Case Number: INSTRUCTIONS TO DEBTOR(S): OFFICE OF EDWINA E. DOWELL, CHAPTER 13 TRUSTEE COMPLETE THIS FORM IF YOU ARE SELF-EMPLOYED (i.e., you work for yourself, you are an independent contractor, or you are paid on commission) CENTRAL DISTRICT OF CALIFORNIA 700 SOUTH FLOWER STREET, SUITE 1950, LOS ANGELES, CA 90017 PREPARE A SEPARATE BUSINESS REPORT FORM FOR EACH BUSINESS. (213) 996-4400 RETURN TO CHAPTER 13 TRUSTEE NOT LATER THAN FIVE (5) DAYS BEFORE THE MEETING/HEARING. SECTION ONE: NATURE OF BUSINESS Name of Business: Number of Employees: Address: Entity: Sole Proprietorship Partnership Phone: Corporation Describe the business (nature of work performed or service provided): If the business is the reason for the bankruptcy, explain why: SECTION TWO: Estimated monthly gross receipts Estimated monthly gross receipts Estimated monthly gross receipts Estimated monthly gross receipts ESTIMATED MONTHLY INCOME: (labor/services) (sales of goods) (other: (other: ) ) TOTAL GROSS RECEIPTS (1) On what do you base your estimates of income? $ $ $ $ $ (Attach copies of all documents which substantiate your estimate): (2) Attach copies of your federal income tax returns (with 1099s) for the prior 2 years. Page 1 of 4 American LegalNet, Inc. www.USCourtForms.com Bus. Rept 5/14/98 CCD-200 SECTION THREE: TOTAL ESTIMATED MONTHLY EXPENSES $ (From attachment A - include estimated cost of goods sold (1)) Total cost of goods (1) and all operating expenses (2) (from attachment A): $ EXCESS OF: $ Total Gross Receipts over costs and expenses OR $ Costs and expenses over total gross receipts On what do you base your estimates of expenses? (Attach copies of all documents which substantiate your estimate): SECTION FOUR: Name of Institution SECTION FIVE: LIST ALL BANK ACCOUNTS Purpose of Account (e.g., Personal, payroll, etc.) (Personal and Business) Nature of Account (e.g., Checking, Savings) Account # Attach list of all inventory, including goods, furniture, equipment and the market value of inventory held by debtor on date of filing. My business has no items of inventory. I declare under penalty of perjury that the information contained in the foregoing Business Report and Attachment A are true and correct to the best of my knowledge, information and belief. Dated this day of , at Los Angeles, California Name of Debtor (print): Signature of Debtor: Name of Co-Debtor (print): Signature of Co-Debtor: Page 2 of 4 American LegalNet, Inc. www.USCourtForms.com Bus. Rept 5/14/98 ATTACHMENT A - DETAIL OF MONTHLY OPERATING EXPENSES 1. Estimated cost of goods sold: $ 2. Estimated operation expenses of business (Do not include any personal expenses. All personal expenses should be listed on Schedule J). Federal income taxes: Self-employment taxes: Federal withholding taxes: State income taxes: State withholding taxes: State sales taxes: Other taxes (itemize): Leases of realty (itemize): Leases of personalty (itemize): Salaries: Employee benefits (itemize): Electricity: Heat: Phone system: Phone bills: Other utilities (itemize): Automobile expenses (itemize): Transportation expenses (itemize): Advertising (itemize): Office equipment (itemize): Office supplies: Page 3 of 4 American LegalNet, Inc. www.USCourtForms.com Bus. Rept 5/14/98 Insurance: Fire (extended coverage on business property and equipment): General Liability: Non-owned vehicle insurance: Other (itemize): Licensing fees (itemize): Other (itemize): TOTAL MONTHLY OPERATING EXPENSES (2): $ Page 4 of 4 American LegalNet, Inc. www.USCourtForms.com Bus. Rept 5/14/98