Monthly Tax Statement1 Debtor: Case Number: Month reported:__________________ GROSS PAYROLL Federal Tax Withheld State Tax Withheld Employer Tax Remittance to IRS Date Remitted Remittance to EDD Date Remitted GROSS SALES Remittance to SBE Date Remitted OTHER TAXES Remittance Date Remitted I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct. Date: _______________ Signature: Print Name: ________________________ ________________________ To comply with the court's Order For Payment Of State And Federal Taxes and the U.S. Trustee Guidelines, attach the signed original of this statement to the Monthly Operating Report filed with court; attach a copy to the copy of the Monthly Operating Report served on the United States Trustee; and transmit a copy of this statement to the IRS and the EDD. This statement is due on or before the 20th day of the month following the month being reported. 1/ American LegalNet, Inc. www.FormsWorkFlow.com