FS-6500-24 Financial Statement

FS-6500-24 (XX/202X)
OMB No. 0596-0082
U.S. DEPARTMENT OF AGRICULTURE
FOREST SERVICE
FINANCIAL STATEMENT
AUTHORITY:
36 CFR 251.54(e)(5)(iv) and FSH 6509.18
INSTRUCTIONS: Provide your most recent fiscal year financial statement. The Forest Service may also request 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. Complete and accurate information must be provided as required in this form. Anyone who knowingly or
willfully makes any false statement or representation on this form is subject to a fine, imprisonment, or both 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 OF
INCORPORATION

3. DATE OF
INCORPORATION

4. ADDRESS OF PRINCIPAL PLACE OF BUSINESS

5. FOR PARTNERSHIPS, NAMES OR PARTNERS AND THEIR PARTNERSHIP INTERESTS:
6. NAME, TITLE, AND ADDRESS OF CORPORATE OFFICERS AND DIRECTORS AND NUMBER OF SHARES OF
STOCK OWNED BY EACH
FULL NAME
TITLE
ADDRESS, TELEPHONE NUMBERS, AND
SHARES OWNED
E-MAIL ADDRESS

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7. REFERENCES (at least three, preferably from banks):
Full Name

ADDRESS, TELEPHONE NUMBERS, AND E-MAIL ADDRESS

You may submit certified financial statements in lieu of completing PARTS A through C below. However, you must
complete either the certification statement in PART D.1 or PART D.2 at the bottom of the last page.
PART A. BALANCE SHEET

CURRENT
YEAR
(MM/DD/YYYY)

PREVIOUS
YEAR
(MM/DD/YYYY)

YEAR BEFORE
PREVIOUS
YEAR
(MM/DD/YYYY)

(

(

(

YEAR ENDED
ASSETS
CURRENT ASSETS
CASH
RECEIVABLES
LESS ALLOWANCES FOR DOUBTFUL
ACCOUNTS
INVENTORIES (LIST MAJOR CATEGORIES)

SUPPLIES AND MISCELLANEOUS ITEMS
MARKETABLE SECURITIES
PREPAID EXPENSES
SUPPLIES INVENTORY
OTHER CURRENT ASSETS

TOTAL CURRENT ASSETS
FIXED ASSETS
LAND
BUILDINGS
MACHINERY AND EQUIPMENT
PLANT
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)

)

)

LEASEHOLD IMPROVEMENTS
OTHER
LESS ALLOWANCE FOR DEPRECIATION

(

)

(

)

(

)

BOOK VALUE OF FIXED ASSETS
OTHER ASSETS
CASH DEPOSITS
SECURITIES
TOTAL OTHER ASSETS
TOTAL ASSETS

LIABLIITIES AND OWNER EQUITY

CURRENT
YEAR
(MM/DD/YYYY)

CURRENT LIABILITIES
ACCOUNTS PAYABLE
ACCRUED PAYROLL
ACCRUED PAYROLL TAXES AND INSURANCE
NOTES PAYABLE
CURRENT INCOME TAXES
OTHER TAXES
CURRENT PORTION OF LONG-TERM DEBT
OTHER CURRENT LIABILITIES (SPECIFY)

TOTAL CURRENT LIABILITIES
OTHER LIABILITIES
DEFERRED INCOME TAXES
LOANS FROM OFFICERS OR PARTNERS
LONG-TERM DEBT LESS CURRENT PORTION OF
LONG-TERM DEBT

TOTAL OTHER LIABILITIES
TOTAL LIABILITIES
OWNER EQUITY
CAPITAL STOCK OUTSTANDING
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PREVIOUS
YEAR
(MM/DD/YYYY)

YEAR BEFORE
PREVIOUS
YEAR
(MM/DD/YYYY)

RETAINED EARNINGS (DEFICIT)
PARTNERS' INVESTMENT (DEFICIT)

TOTAL OWNER EQUITY
TOTAL LIABILITIES AND OWNER EQUITY
PART B. SUPPLEMENTAL DATA
THE INCOME STATEMENT IN PART C IS CASH BASIS
INVENTORIES ARE LIFO

, FIFO

ACCRUAL BASIS

.

, COST, OR MARKET, WHICHEVER IS LOWER

.

NAME, ADDRESS, TELEPHONE NUMBERS, AND E-MAIL ADDRESS OF CONTRACTORS OR SUBCONTRACTORS
USED TO PREPARE THE INCOME STATEMENT IN PART C (IF ANY):

PART C. INCOME STATEMENT

CURRENT
YEAR
(MM/DD/YYYY)

PREVIOUS
YEAR
(MM/DD/YYYY)

YEAR
BEFORE
PREVIOUS
YEAR
(MM/DD/YYYY)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

(

)

INCOME TAXES

(

)

(

)

(

)

OTHER EXPENSES

(

)

(

)

(

)

(

)

(

)

(

)

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)
PLUS OTHER INCOME
LESS INTEREST EXPENSE

NET AMOUNT OF OTHER INCOME AND EXPENSES
NET PROFIT (LOSS) FOR YEAR:

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PART D.1. CERTIFICATION FOR CORPORATIONS, LLCs, AND PARTNERSHIPS
We, the undersigned, general officers (or members) of
[name of corporation, LLC, or partnership], swear
that the above or attached financial statements are true and correct and cover all of the financial affairs of [name
of corporation, LLC, or partnership] up to and including [date].
CERTIFYING OFFICIAL'S NAME AND TITLE

SIGNATURE (Sign in ink)

DATE

CERTIFYING OFFICIAL'S NAME AND TITLE

SIGNATURE (Sign in ink)

DATE

SUBSCRIBED AND SWORN TO before me this
SIGNATURE

day of
TITLE

, [year].

PART D.2. CERTIFICATION FOR INDIVIDUALS
I swear that the above or attached financial statements are true and correct.
INDIVIDUAL'S NAME AND TITLE
SIGNATURE (Sign in ink)
SUBSCRIBED AND SWORN TO before me this
SIGNATURE

day of
TITLE

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[year].

(Affix
Notary
Seal)
DATE
(Affix
Notary
Seal)

PAPERWORK REDUCTION ACT STATEMENT
According to the Paperwork Reduction Act of 1995, a Federal agency may not conduct or sponsor, and a person is not required to respond to, an
information collection request unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this
information collection request is 0596-0082. Response to this information collection request is required to obtain or retain benefits, specifically, a special
use authorization. The authority for this information collection request is the 36 CFR 251.54(e)(5)(iv) and FSH 6509.18. The time required to complete
this information collection request is estimated to average 8 hours per response, including the time for reviewing instructions, searching existing data
sources, collecting and maintaining the data needed, and completing and reviewing the information collection request. Send comments regarding this
burden estimate or any other aspect of this information collection request, including suggestions for reducing the burden, to Forest Service Information
Collections Officer, SM.FS.InfoCollect@usda.gov, with OMB control number 0596-0082 in the subject line.
PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act statement serves to inform you of the following concerning the collection of the information on this
form.
Purpose: The Privacy Act of 1974 requires that the Director of Recreation, Heritage, and Volunteer Resources staff and the Director of Lands, Minerals,
and Geology Management staff provide the following statements to individuals from whom they request information.
Authority: Collection of this information solicited on this form is authorized by the 36 CFR 251.54(e)(5)(iv) and FSH 6509.18.
Routine Uses: The information collected will be used by Forest Service officials to ensure that your use of National Forest System lands is
administered in accordance with applicable statutes, regulations, and directives. The information collected from you is retained in the Special Uses Data
System (SUDS) and is retrieved by the Forest Service create reports for the Agency’s Special Uses Program, generate bills for collection of land use
fees for your authorization, monitor compliance with your special use authorization, and other matters pertaining to administration of your special use
authorization. SUDS is a component of the Forest Service’s Natural Resources Manager database (NRM). A complete list of the routine uses of NRM
can be found in the system of records notice associated with this form, FS-24.
Disclosure: The submission of this information is required to obtain or retain benefits, specifically, a special use authorization.
NONDISCRIMINATION STATEMENT
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies,
offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national
origin, religion, sex, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or
retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and
complaint filing deadlines vary by program or incident.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign
Language, etc.) should contact the State or local Agency that administers the program or contact USDA through the Telecommunications Relay Service
at 711 (voice and TTY). Additionally, program information may be made available in languages other than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a
Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all the information requested in
the form. To request a copy of the complaint form, call (866) 632-9992. Submit the completed form or letter to USDA by (1) mail: U.S. Department of
Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442;
or (3) email: program.intake@usda.gov.
USDA is an equal opportunity provider, employer, and lender.

U.S. GPO: 1996-720-508

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