15-Financial Statement (CSCD Fillable).pdf
PDF 49 KB Posted
- Attached to
- RFP - Telepsychiatry Services for Harris County Community Supervision & Corrections Department
- Solicitation number
- 26/0006
- Issued by
- Harris County, Texas
About this file
This is a Financial Statement form (CSCD Fillable) used by the Harris County Community Supervision & Corrections Department for vendor financial disclosure requirements related to the Telepsychiatry Services RFP. The document is a standardized financial statement template requiring vendors to report their financial condition as of a specified month and year, serving as a compliance document to assess vendor financial stability and capability to perform contract obligations.
The form is divided into two sections: Assets and Liabilities and Net Worth. The Assets section requests detailed accounting of cash holdings, accounts receivable from completed and uncompleted contracts, bid deposits, notes receivable, interest earned, real estate valuations, stocks and bonds, equipment and machinery (net of depreciation), and other assets. The Liabilities and Net Worth section requires documentation of notes payable to banks and equipment obligations, current and past-due accounts payable, real estate mortgages, other liabilities, reserves, and capital stock information (both common and preferred), concluding with a surplus calculation. This financial disclosure form enables Harris County to evaluate vendor financial viability and creditworthiness prior to award of telepsychiatry services contracts.
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Text version
FINANCIAL STATEMENT
Condition of vendor at close of business Month, ______________________, 20__.
ASSETS
1. Cash on hand $
In Bank $
Elsewhere $ $
2. Accounts receivable from completed contracts (exclusive of claims not approved for payment)
3. Accounts receivable from other sources than above
4. Amounts earned on uncompleted contracts (not included in Item 3) (Contract price on completed portion of uncompleted contracts less total cost of completed portion.)
5. Deposits for bids or other guarantees
6. Notes receivable Past due $
Due 90 days $ Due Later $
7. Interest earned
8. Real Estate Business Property, Present value $
Other property $
9. Stocks and Bonds $
Listed on exchange $ Unlisted $
10. Equipment, machinery, fixtures $ Less Depreciation $
11. Other Assets
TOTAL ASSETS $
LIABILITIES AND NET WORTH
1. Notes Payable To banks regular $
(For certified check)
Equip. Obligations
Others $
2. Accounts Payable Current $
Past Due
3. Real Estate Mortgages
4. Other Liabilities
5. Reserves
6. Capital Stock Paid up Common
Preferred
7. Surplus
TOTAL LIABILITIES $
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