CASE NAME: CASE NUMBER:
 
 

BEGINNING BALANCE (ending balance from last month) $
 

RECEIPTS (Summary of all accounts):

1. Receipts from operations $

2. Other receipts $
 

TOTAL RECEIPTS (A) $
 

DISBURSEMENTS (Summary of all accounts):

1. Net payroll

a. Officers $

b. Others $
 

2. Taxes paid or deposited:

a. Fed. income tax w/held $

b. FICA $

c. State income tax w/held $

d. State sales or use tax $

e. Other (specify)

$

$

3. Necessary expenses:

a. Merchandise bought for

manufacture or sale $

b. Other necessary expenses $
 

TOTAL DISBURSEMENTS (B) $
 

NET RECEIPTS (Line (A) less Line (B)) $

ENDING BALANCE (BEGINNING BALANCE PLUS NET RECEIPTS) $
 

NOTE: Attach a copy of the most recent bank statement and a reconciliation for each account.
 

* If you have more than one account, the activity in all accounts should be summarized on this page.
 
 

Bank:_____________________________ Account#____________________________
 
 

DATE RECEIVED

SUBTOTAL $______________

MINUS TRANSFERS FROM OTHER ACCOUNTS $______________

(provide detail above)

TOTAL $______________

(transfer to Line A, Page 1)
 

Receipts may be identified by major categories. It is not necessary to list each transaction separately. You must, however, create a separate list for each bank account.
 
 

Bank: _____________________________________________
 

Acct. No.: _____________________________________________
 

Account Name: _____________________________________________
 

Location: _____________________________________________
 
 
 
 
 

Please list all disbursements made during the month on the attached page. All payroll checks should be listed separately, including the employee's name. You must create a separate list for each bank account. Include any bank service charges/fees and any automatic deductions.
 
 
 
 
 
 
 

TOTAL DISBURSEMENTS $ _____________________
 

MINUS TRANSFERS TO OTHER ACCOUNTS $ _____________________

(provide detail)
 

TOTAL MONTHLY DISBURSEMENTS $ _____________________

(This figure should be transferred to line B of the Summary Page)
 
 
 
 
 

DATE PAID	CHECK NO.	PAYEE	DESCRIPTION	AMOUNT

 
 
 
 
 
 
 
 
 

Beginning inventory $_____________________________
 

Add: purchases $_____________________________
 

Less: goods sold (cost basis) $_____________________________
 

Ending inventory $_____________________________
 
 

*State reason for non-payment.
 

ACCOUNTS RECEIVABLE:
 

Beginning of month balance $___________________

Add: sales on account $___________________
 

Less: collections $___________________
 

End of month balance $___________________

0-30 Days
 
 
 

$_________

31-60 Days
 
 
 

$__________

61-90 Days
 
 
 

$_________

Over 90 Days
 

$________

End of Month Total
 

$__________
 
 

Beginning of month balance $___________________

Add: credit extended $___________________
 

Less: payments on account $___________________
 

End of month balance $___________________

0-30 Days
 
 
 

$_________

31-60 Days
 
 
 

$__________

61-90 Days
 
 
 

$_________

Over 90 Days
 

$________

End of Month Total
 

$__________
 
 
 
 
 

ITEMIZE ALL POST PETITION PAYABLES OVER 30 DAYS OLD.
 

Debtors in possession and trustees are required to pay all taxes incurred after the filing of their Chapter 11 petition as the taxes come due. Please indicate whether the following post-petition taxes have been paid or deposited as they came due.
 

( ) Check here if no employees.
 

TAX	YES	NO	NOT REQUIRED	WHEN DUE
Federal income tax withholding
FICA withholding
Employer's share FICA
Federal Unemployment Taxes
State Income Tax Withholding
Sales Tax
Other tax

 

If any taxes have not been paid when due complete this table:
 

TAX NOT PAID	AMOUNT NOT PAID	DATE OF LAST PAYMENT	WHY TAX NOT PAID

 

NOTE: Attach Verification of Fiduciary's Federal Tax Deposit (IRS Form 6123)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Form 6123 (Rev. 06-97)	Department of the Treasury-Internal Revenue Service Verification of Fiduciary's Federal Tax Deposit
Do not attach this Notice to your Return
TO		District Director, Internal revenue Service Attn: Chief, Special Procedures Function
FROM:		Name of Taxpayer
		Taxpayer Address
The following information is to notify you of Federal tax deposit(s)(FTD) as required by the United States Bankruptcy Court (complete sections 1 and/or 2 as appropriate):
Section 1 Taxes Reported on Form 941, Employer's Quarterly Federal Tax Return			Form 941 Federal Tax Deposit (FTD) Information for the payroll period from to  Payroll date  Gross wages paid to employees $ Income tax withheld $ Social Security (Employer's plus Employee's  share of Social Security Tax) $ Tax Deposited $ Date Deposited
Section 2 Taxes Reported on Form 940,Employer's Annual Federal Unemployment Tax Return			Form 940 Federal Tax Deposit (FTD) Information for the payroll period from to  Gross wages paid to employees $ Tax Deposited $ Date Deposited
Certification (Certification is limited to receipt or electronic transmittal of deposit only) This certifies receipt or electronic transmittal of deposits described below for Federal taxes as defined in Circular E, Employer's Tax Guide (Publication 15)
Deposit Method Form 8109/8109B Federal Tax Deposit (FTD) coupon (check box) Electronic Federal Tax Payment System (EFTPS) Deposit
Amount (Form 941 Taxes				Date of Deposit	EFTPS acknowledgment number or Form 8109 FTD received by:
Amount (Form 940 Taxes				Date of Deposit	EFTPS acknowledgment number or Form 8109 FTD received by:
Depositor's Employer Identification Number:					Name and Address of Bank
Under penalties of perjury, I certify that the above federal tax deposit information is true and correct
Signed: Date:
Name and Title (print or type)