Cobb County Business License Division 1 New Alcoholic Beverage ...

Cobb County Business License Division 27New Alcoholic Beverage Establishment ApplicationRevised 3/10OWNER/LICENSEE PERSONAL FINANCIAL STATEMENT (Confidential)Name`Social Security No.Residence AddressCity, State, ZipDate of BirthName of SpouseBusiness or OrganizationBusiness PhoneResidence Phone Partner or Officer in any other business? ( ) Yes ( ) NoAssetsCash on hand and in banksAccounts receivableNotes receivableStocks and BondsReal EstateCash value of life insuranceAutomobiles% Interest LiabilitiesNotes Payable to Banks-SecuredNotes Payable to Banks-UnsecuredNotes Payable to OthersAccounts PayableUnpaid TaxesMortgages on Real EstateOther DebtsDeposit accountsCredit with financial institutionsOther assets (itemize):Total LiabilitiesNet WorthTotal AssetsTotal Liabilities and Net WorthSource of Annual IncomeSalaryBonus and CommissionsDividendsAlimony, child support, or separate incomeItemize all loan sources and interest:Other income (itemize)TotalGeneral InformationUnsatisfied judgments or law suits pending? Yes ( ) NoAre any income tax returns made by you for prior years being contested?( ) Yes ( ) NoIf so, what do you estimate as the additional amount you may be required topay?Are any assets pledged or in joint names other than as described above?( ) Yes ( ) NoHave you ever been declared bankrupt? Yes ( ) NoDo you have a will? Yes ( ) No Beneficiary(ies): Who is named as your executor?As of ___________ , 20 ____.