Appendix 17 FS_6500_24 Financial Statement 508c.pdf
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- Chequamegon-Nicolet National Forest Prospectus for Campground and Related Granger-Thye Concessions
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Department of Agriculture Forest Service
About this file
This is the FS-6500-24 Financial Statement form, a required federal contracting document used by the U.S. Department of Agriculture Forest Service to evaluate the financial capability of respondents to Granger-Thye concession opportunities on the Chequamegon-Nicolet National Forest. The form requests comprehensive financial data from corporations, limited liability companies, partnerships, and proprietorships seeking to operate campgrounds and related concessions on federal forest lands.
Respondents must provide the most recent fiscal year financial statement, with the Forest Service retaining the discretion to request two additional years of historical financial data on a case-by-case basis. The form requires detailed information including organizational structure, incorporation details, principal business addresses, corporate officers and directors with shareholdings, and at least three references preferably from banking institutions. Part A requests a complete balance sheet covering current and past years with line items for current assets, fixed assets, liabilities, and owner equity. Part B requires supplemental accounting data specifying whether statements are prepared on a cash or accrual basis and inventory valuation methods. Part C requests a three-year income statement detailing gross sales, cost of goods sold, operating expenses, and net profit or loss. Respondents may submit certified financial statements in lieu of completing Parts A through C. Certification under Part D requires sworn statements from corporate officers, LLC members, or partnerships, or an individual affidavit certifying the accuracy and completeness of all financial information. False or fraudulent financial reporting is subject to criminal penalties under 18 U.S.C. 1001(a). The estimated burden for completing this form is eight hours per response.
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United States Department of Agriculture
Prospectus for Campground and Related Granger-Thye Concessions Chequamegon-Nicolet National Forest
Appendix 17: FS-6500-24, Financial Statement
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)
USDA Forest Service FS-6500-24 (V. 07/2012)
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.
USDA Forest Service FS-6500-24 (V. 07/2012)
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)
USDA Forest Service FS-6500-24 (V. 07/2012)
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
USDA Forest Service FS-6500-24 (V. 07/2012)
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
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
PART D (1). CERTIFICATION FOR CORPORATIONS, LIMITED LIABILITY COMPANIES OR PARTNERSHIPS
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