AppE_FSFinancialForms.pdf

APPENDIX E – Forest Service Form FS-6500-24, Financial Statement and Forest Service Form FS-6500-25, Request for Verification

USDA Forest Service FS-6500-24 (V. 07/2012) OMB No. 0596-0082

FINANCIAL STATEMENT

(Ref. 36 CFR 223.7(e), 36 CFR 251.54(e)(2), Federal Acquisition Regulation 48 CFR 9.104-1.)

INSTRUCTIONS: Forest Service (FS) requires the respondent to provide the most recent fiscal year financial statement.

FS may also request the respondent to provide two additional years of financial data, on a case by case basis. If more space is needed to fully answer any item below, attach additional sheets. False or fraudulent financial reporting on this form is subject to a fine or imprisonment under 18 U.S.C. 1001(a).

1. NAME OF CORPORATION, LIMITED LIABILITY COMPANY (LLC.), PARTNERSHIP, OR PROPRIETORSHIP (include any names the organization/firm operated under during past three years and specify the year operated for each name):

2. STATE

INCORPORATED

3. DATE INCORPORATED 4. ADDRESS OF PRINCIPAL PLACE OF BUSINESS (with

ZIP CODE)

5. IF PARTNERSHIP, NAMES OR PARTNERS, AND THEIR PARTNERSHIP INTERESTS

6. NAMES, TITLES, AND ADDRESSES OF CORPORATE OFFICERS AND DIRECTORS, WITH NUMBER OF SHARES

OF STOCK OWNED BY EACH

FULL NAME TITLE ADDRESS

(Number, Street, City, State, and ZIP CODE)

SHARES

OWNED

7. REFERENCES (At least three should be given, preferable banks):

Full Name ADDRESS (Number, Street, City, State, and ZIP CODE)

PART A. BALANCE SHEET

CURRENT YEAR PAST YEAR THIRD YEAR

(MO/DA/YR) (MO/DA/YR) (MO/DA/YR)

YEAR ENDED

ASSETS

CURRENT ASSETS:

CASH

RECEIVABLES-TRADE

LESS ALLOWANCES FOR DOUBTFUL ACCOUNTS < > < > < >

INVENTORIES (LIST MAJOR CATEGORIES):

SUPPLIES AND MISCELLANEOUS

MARKETABLE SECURITIES

PREPAID EXPENSES

SUPPLIES INVENTORY

OTHER CURRENT ASSETS:

TOTAL CURRENT ASSETS

FIXED ASSETS:

LAND

BUILDINGS

MACHINERY AND EQUIPMENT

PLANT

LEASEHOLD IMPROVEMENTS

OTHER

LESS ALLOWANCE FOR DEPRECIATION < > < > < >

BOOK VALUE-FIXED ASSETS

NOTE: Respondents may submit certified financial statements in lieu of answering PARTS A through C on the next pages. However, respondents must complete either certification statement PART D (1) or PART D (2) at the bottom of the last page.

OTHER ASSETS:

DEPOSITS-CASH

DEPOSITS-SECURITIES

TOTAL-OTHER ASSETS

TOTAL ASSETS

LIABLIITIES AND OWNER EQUITY CURRENT

YEAR

PAST YEAR THIRD YEAR

CURRENT LIABILITIES:

ACCOUNTS PAYABLE-TRADE

ACCRUED PAYROLL

ACCRUED PAYROLL TAXES AND INSURANCE

NOTES PAYABLE

INCOME TAXES-CURRENT

OTHER TAXES

CURRENT PORTION OF LONG-TERM DEBT

OTHER CURRENT LIABILITIES (SPECIFY):

TOTAL CURRENT LIABILITIES

OTHER LIABILITIES:

DEFERRED INCOME TAXES

LOANS FROM OFFICERS/PARTNERS

LONG-TERM OBLIGATIONS-LESS CURRENT AMOUNT

TOTAL OTHER LIABILITIES

TOTAL LIABILITIES

OWNER EQUITY:

CAPITAL STOCK OUTSTANDING

RETAINED EARNINGS (DEFICIT)

PARTNERS' INVESTMENT (DEFICIT)

TOTAL OWNER EQUITY

TOTAL LIABILITIES AND OWNER EQUITY

PART B. SUPPLEMENTAL DATA

THIS STATEMENT IS ON THE-CASH BASIS ACCRUAL BASIS

INVENTORIES ARE-LIFO FIFO COST OR MARKET WHICHEVER IS LOWER

NAMES OF CONTRACTORS OR SUB-CONTRACTORS USED (IF ANY):

PART C. INCOME STATEMENT CURRENT YEAR PAST YEAR THIRD YEAR

GROSS SALES

LESS-RETURNS AND ALLOWANCES < > < > < >

NET SALES

LESS-COST OF GOODS SOLD < > < > < >

GROSS PROFIT ON SALES

LESS-SELLING EXPENSE < > < > < >

NET PROFIT (LOSS) ON SALES

GENERAL EXPENSE:

OFFICERS SALERIES

LEGAL AND OTHER PROFESSIONAL EXPENSE

OFFICE EXPENSE

TOTAL GENERAL EXPENSE

NET OPERATING PROFIT (LOSS)

ADD-OTHER INCOME

LESS-INTEREST EXPENSE

INCOME TAXES < > < > < >

OTHER EXPENSE < > < > < >

NET AMOUNT OF OTHER INCOME AND EXPENSE < > < > < >

NET PROFIT (LOSS) FOR YEAR

NOTE: Offers must set forth full, accurate, and complete information as required in this Financial Statement (including any attachments). The penalty for making false statements in this Financial Statement is prescribed in 18 U.S.C. 1001.

PART D (1). CERTIFICATION FOR CORPORATIONS, LIMITED LIABILITY COMPANIES OR PARTNERSHIPS We, the undersigned, general officers (or members) of (Name of corporation, LLC. or partnership) being severally sworn, each declares that the above or attached financial statements are true and correct, and that it covers all of the financial affairs of said company (or) firm up to and including the date of 2 .

CERTIFYING OFFICIAL'S NAME AND TITLE SIGNATURE (Sign in ink) DATE

CERTIFYING OFFICIAL'S NAME AND TITLE SIGNATURE (Sign in ink) DATE

SWORN TO AND SUBSCRIBED before me this day of (Month/Year). (Affix Notary Seal)

SIGNATURE TITLE

PART D (2). CERTIFICATION FOR INDIVIDUALS

I swear (or affirm) that the above or attached financial statements are true and correct to the best of my knowledge.

INDIVIDUAL'S NAME AND TITLE SIGNATURE (Sign in ink) DATE

SWORN TO AND SUBSCRIBED before me this day of (Month/Year) (Affix Notary Seal) SIGNATURE TITLE

Burden Statement According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596- 0082. The time required to complete this information collection is estimated to average 8 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250- 9410, or call toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or at (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.

The Privacy Act of 1974 (5 U.S.C. 552a) and the Freedom of Information Act (5 U.S.C. 552) govern the confidentiality to be provided for information received by the Forest Service.

�U.S. GPO: 1996-720-508

US DEPARTMENT OF AGRICULTURE, FOREST SERVICE

REQUEST FOR VERIFICATION

(Reference FSH 6509.18)

FS-6500-25 (V. 07/2012)

OMB No. 0596-0082

Instructions: Applicant - Complete items 1 thru 5. Forward directly to bank or lending institution.

Bank or Lender -

Please complete Items 6 thru 15. Return directly to Resource Audit Branch, CFO Office, Albuquerque Service Center, Forest Service.

101 B Sun Ave., NE, Albuquerque, NM 87109 Attn:

PART I - REQUEST

1. TO: Name and Address of Bank or other Lending institutions

2. FROM: (Name and Address of Applicant)

3. STATEMENT OF APPLICANT

TYPE OF ACCOUNT ACCOUNT NUMBER CURRENT BALANCE

CHECKING ACCOUNT

SAVINGS ACCOUNT

OTHER

I have applied for a timber sale contract or concessionaire permit (please cross one out) with the National Forest and state that my balance with the bank or lending institution named in Item 1 are as shown in Item 3. My signature below authorizes verification of the information. Your response is solely a matter of courtesy for which no responsibility is attached to your institution or any of your officers.

4. Signature of Applicant 5. Date

PART II - VERIFICATION

6. Does applicant have any outstanding loans? 10. Is the account less than 2 months old?

Yes No If yes, fill Item 7. Yes No If Yes, fill in Item 11.

TYPES OF LOANS MONTHLY PYMT. PRESENT BALANCE 11. Date account was opened:

Secured

12. Payment Experience:

Unsecured Favorable Unfavorable

8. Is applicant's statement in Item 3 correct? If unfavorable, please explain in remarks.

Yes No If no, fill Item 9.

9. CURRENT BALANCES

CHECKING SAVINGS

13. REMARKS:

THE INFORMATION ON THIS FORM IS CONFIDENTIAL. IT IS TO BE TRANSMITTED DIRECTLY, WITHOUT

PASSING THOROUGH THE HANDS OF THE APPLICANT OR ANY OTHER PARTY.

14. Signature of bank or lending official. 15. Date

False or fraudulent financial reporting on this form is subject to a fine or imprisonment under 18 U.S.C. 1001(a).

Burden Statement According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596- 0082. The time required to complete this information collection is estimated to average 0.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250- 9410, or call toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or at (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.

The Privacy Act of 1974 (5 U.S.C. 552a) and the Freedom of Information Act (5 U.S.C. 552) govern the confidentiality to be provided for information received by the Forest Service.