Form 19-6A "Financial Report" - Georgia (United States)

What Is Form 19-6A?

This is a legal form that was released by the Georgia Department of Banking and Finance - a government authority operating within Georgia (United States). As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2007;
  • The latest edition provided by the Georgia Department of Banking and Finance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 19-6A by clicking the link below or browse more documents and templates provided by the Georgia Department of Banking and Finance.

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Download Form 19-6A "Financial Report" - Georgia (United States)

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Banking & Finance
Form 19-6a
Revised 10-2007
FINANCIAL REPORT
I,
,
(Name)
(Business Address)
submit herewith the following information and a correct and complete statement of my financial condition as of
to the
(Date)
Department of Banking and Finance for its confidential use, in connection with my service as a bank director in Georgia to comply with
the requirements of Rule 80-1-6-.03 and/or by an executive officer of a Georgia bank to comply with bank policy.
(Reason for submitting report)
An answer to each item is required. If the answer is "No", "None" or "Not applicable", so state. If an item of information called for is unknown, so state. If
space provided on this form is inadequate, attach a separate schedule. All such schedules should be signed and dated.
Business telephone number:
Home telephone number:
ASSETS
LIABILITIES
1) Cash on hand and in banks
$
9) Accounts payable
$
2) Notes, loans and other accounts receivable
10) Notes payable to banks - from schedule D
considered good and collectible
3) Merchandise and inventory at lower cost or
11) Notes payable to others - from Schedule E
market value
4) Real estate - from Schedule A
12) Real estate mortgages - from Schedule F
5) Machinery and equipment - at cost less
13) Interest and taxes due and unpaid - from
depreciation
Schedule G
6) Marketable securities - from Schedule B
14) Other debts and liabilities-from Schedule H
7) Life insurance (face amount $
)
TOTAL LIABILITIES
cash surrender value
8) Other assets - from Schedule C
15) NET WORTH
TOTAL LIABILITIES
TOTAL ASSETS $
AND NET WORTH
$
NOTE: Notes, accounts receivable, mortgages and other assets considered doubtful, and not included in above financial statement have an estimated value of $
.
CONTINGENT LIABILITIES
In addition to the debts and liabilities listed above, I have endorsed, guaranteed, or am otherwise indirectly or contingently liable for the debts of
others as follows:
Name and Address
Name and Address of
Description of
Value of
Date Obligation
Current
of Debtor or Obligor
Creditor or Obligee
Collateral
Collateral
Incurred
Due
Amount
$
$
TOTAL
$
Attach additional information on a separate sheet of paper if necessary
Banking & Finance
Form 19-6a
Revised 10-2007
FINANCIAL REPORT
I,
,
(Name)
(Business Address)
submit herewith the following information and a correct and complete statement of my financial condition as of
to the
(Date)
Department of Banking and Finance for its confidential use, in connection with my service as a bank director in Georgia to comply with
the requirements of Rule 80-1-6-.03 and/or by an executive officer of a Georgia bank to comply with bank policy.
(Reason for submitting report)
An answer to each item is required. If the answer is "No", "None" or "Not applicable", so state. If an item of information called for is unknown, so state. If
space provided on this form is inadequate, attach a separate schedule. All such schedules should be signed and dated.
Business telephone number:
Home telephone number:
ASSETS
LIABILITIES
1) Cash on hand and in banks
$
9) Accounts payable
$
2) Notes, loans and other accounts receivable
10) Notes payable to banks - from schedule D
considered good and collectible
3) Merchandise and inventory at lower cost or
11) Notes payable to others - from Schedule E
market value
4) Real estate - from Schedule A
12) Real estate mortgages - from Schedule F
5) Machinery and equipment - at cost less
13) Interest and taxes due and unpaid - from
depreciation
Schedule G
6) Marketable securities - from Schedule B
14) Other debts and liabilities-from Schedule H
7) Life insurance (face amount $
)
TOTAL LIABILITIES
cash surrender value
8) Other assets - from Schedule C
15) NET WORTH
TOTAL LIABILITIES
TOTAL ASSETS $
AND NET WORTH
$
NOTE: Notes, accounts receivable, mortgages and other assets considered doubtful, and not included in above financial statement have an estimated value of $
.
CONTINGENT LIABILITIES
In addition to the debts and liabilities listed above, I have endorsed, guaranteed, or am otherwise indirectly or contingently liable for the debts of
others as follows:
Name and Address
Name and Address of
Description of
Value of
Date Obligation
Current
of Debtor or Obligor
Creditor or Obligee
Collateral
Collateral
Incurred
Due
Amount
$
$
TOTAL
$
Attach additional information on a separate sheet of paper if necessary
If more than six months
STATEMENT OF INCOME
20
20
20
CURRENT
YEAR
Salaries, wages, and commissions from employment
Income from dividends and interest
Net income from rents, royalties and investments
Other income
TOTAL INCOME
Expenses
NET INCOME
SUPPORTING SCHEDULES
Schedules set forth on this page must agree in total with the appropriate item contained in the Financial Statement on Page 1 of this report.
Schedule A - Real Estate Owned
Description and Location
Title in Whose Name
Date Acquired
Cost
Insurance
Current Value
$
carried forward to item 4, page 1
TOTAL
$
Schedule B - Marketable Securities
Description
Amount
Description
Amount
$
$
carried forward to item 6, page 1
TOTAL
$
Schedule C - Other Assets
Schedule D - Notes Payable to Banks
Description and Basis for Valuation
Value
Name of Creditor
Security
Date Due
Amount
$
$
carried forward to item 8, page 1 TOTAL
$
carried forward to item 10, page 1
TOTAL
$
Schedule E - Notes Payable to Others
Schedule F - Real Estate Mortgages Payable
Name of Creditor
Security
Date Due
Amount
Name of Creditor Location of Property Date Due
Amount
$
$
carried forward to item 11, page 1 TOTAL
$
carried forward to item 12, page 1 TOTAL
$
Schedule G - Interest and Taxes Due and Unpaid
Schedule H - Other Debts and Liabilities
Description
Payable To
Date Due
Amount
Description
Date Due
Amount
$
$
carried forward to item 13, page 1 TOTAL
$
carried forward to item 14, page 1
TOTAL
$
CERTIFICATE
I hereby certify that the foregoing information and statement of financial condition is true and correct to the best of my knowledge
and belief and that said information and statement of financial condition are submitted voluntarily by me to the Department of
Banking and Finance for its confidential use.
(Date)
(Signature in Full)
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