THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: STATEMENT OF ASSETS AND LIABILITIES FOR A BUSINESS 1. Name of Business: 2. Type of business entity: 3. Name of person completing form/title(authorized agent/officer): 4. Address: 5. Mailing Address (if different): 6. Please list the name, address and percentage of ownership for all owners of the business entity: 7. Please state monthly: Income/revenue from sales/services ..................... $ Other Income ......................................................... $ (describe source of other income) Total $ 8. Please state monthly operating expenses for the business: Rent/Mortgage ....................................................... $ Property taxes ....................................................... $ Insurance ............................................................... $ Transportation ....................................................... $ Cost of goods sold ................................................. $ Compensation: to officers/owners .................................................. $ Other payroll .......................................................... $ Loan payments ...................................................... $ (please list all loans and payment status) Other (specify) $ Total $ NHJB-4009-Se (07/01/2018) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: STATEMENT OF ASSETS AND LIABILITIES FOR A BUSINESS 9. List the value of all Assets owned by the business Cash on hand ........................................................ $ Inventory ................................................................ $ Equipment ............................................................. $ Vehicles ................................................................. $ Real Estate ............................................................ $ Total $ 10. List the location, including street address, of any real estate owned by the business: 11. List taxes paid last year by the business: 12. Other than monthly expenses, list any other business expenses/debts currently owed, including court ordered payments, including the amount and the party/entity to whom the obligation is owed: 13. Please list outstanding receivables. Include the amount owed and the party/entity from whom the debt is owed: 14. List any property which has been transferred by the business to any officer, director, owner or a family member of any of those individuals including any business entity owned or controlled by those individuals, within the last four years. For each item, please describe the property transferred, the person or entity receiving the property and the amount paid for that property: 15. List any other assets, income or expenses not previously mentioned: 16. Has the business changed it222s name? If yes, indicate the former name and the date the change occurred: 17. Is the business owned by a parent company? If so, indicate the name of the company. NHJB-4009-Se (07/01/2018) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: STATEMENT OF ASSETS AND LIABILITIES FOR A BUSINESS For non e-filed cases: I state that on this date I am mailing by U.S. mail, or Email (only when there is a prior agreement of the parties to use this method), or hand delivering a copy of this document to: or Other party Other party222s attorney OR For e-filed cases: I state that on this date I am sending a copy of this document as required by the rules of the court. I am electronically sending this document through the court222s electronic filing system to all attorneys and to all other parties who have entered electronic service contacts (email addresses) in this case. I am mailing or hand-delivering copies to all other interested parties. Name of Filer Signature of Filer Date Law Firm, if applicable Bar ID # of attorney Telephone Address E-mail City State Zip code NHJB-4009-Se (07/01/2018) Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com