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

What Is Form 19-6?

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

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Banking & Finance
Form 19-6
FINANCIAL REPORT
Revised 10/2007
Section 1
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
.
(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 19-6
FINANCIAL REPORT
Revised 10/2007
Section 1
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
.
(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
$
BIOGRAPHICAL INFORMATION
SECTION 2
Date of Birth
Place of Birth
Citizenship
Residence Address
Length of Residence in Community
Wife/Husband’s Name
Marital Status
Social Security Number or assigned Internal Revenue Identification Number
Trade names and/or other names used in place of given name
List civic, professional, social or other organizations in which you have membership
Resume of Education
Have you ever been adjudged a bankrupt or had to work out a compromise with your creditors?
If
so, set forth details in the following schedule.
Title and Nature of Proceeding
Date
Name and Address of Court
Disposition
Give details of all pending civil litigation of any nature in which involved either as plaintiff or defendant.
Title and Nature of Lawsuit or Proceeding
Date
Name and Address of Court Where Pending
Disposition
Have you ever been convicted of, or pleaded nolo contendere to, any criminal offense involving dishonesty or breach of trust?
Employment Record
(Include present and all past employment)
Date
Name, Location and Type of Business
Position Held and Nature of Duties
From
To
Business Affiliations
List all firms, companies, corporations or other business organizations of which you are at present a director, officer, empl oyee, partner or
owner.
Name and Location
Type of Business
Position Held
Stock of this bank owned or subscribed for:
Number of Shares
Par Value $
Total Cost $
Method of Payment
If a loan is to be made to purchase this stock, give details.
Name of Lender
Date
Interest Rate
Amount
Security
Repayment Terms
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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