FinancialStatementForm_FS6500-24.docx

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

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

SHARES OWNED

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

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

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.

PART A. BALANCE SHEET

CURRENT YEAR PAST YEAR THIRD YEAR

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

ASSETS

PREPAID EXPENSES

SUPPLIES INVENTORY

OTHER CURRENT ASSETS:

FIXED ASSETS:

LAND

BUILDINGS

MACHINERY AND EQUIPMENT

PLANT

LEASEHOLD IMPROVEMENTS

OTHER

OTHER LIABILITIES:

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

NET SALES

GROSS PROFIT ON SALES

GENERAL EXPENSE:

NET OPERATING PROFIT (LOSS)

ADD-OTHER INCOME

LESS-INTEREST 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

CERTIFYING OFFICIAL'S NAME AND TITLE

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