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     Illinois Department of Revenue

     EG-13-B                        Financial and Other Information Statement for Businesses     
     Note: We may require support for amounts shown on this form.

Step 1:  Tell us about your business

 1   Business name  ______________________________________________________________________________                                                                                                                   

   Address  ____________________________________________________________________________________                                                                                                                      

     ____________________________________________________________________________________ 
     City                                                                                                                                 State                                   Zip

  2  Business phone (____)______________________                                                                                                                                                                       

  3  Federal employer identification number (FEIN)  ____  ____  -  ____  ____  ____  ____  ____  ____  ____                                                                             

  4  Illinois account ID  _____________________________________ 

Step 2:  Tell us about your bank accounts and credit card receivables                                                                                                                                                 
     Attach additional sheets in the same format, if necessary.
a Bank accounts (include payroll and general, savings, certificates of deposit, etc.)
     A                                                            B                      C                                                                                           D               E
     Name of institution                                          Address                Type of account                                                                             Account number  Balance

 5  __________________     ______________________________________________                ________________ ________________                                                                          ________________

 6  __________________     ______________________________________________                ________________ ________________                                                                          ________________

b Current credit card processor and associated receivables
           A                                                                        B                                                                                                C 
      Name of credit card processor                                          Address                      Current receivables 

  7 __________________________  ________________________________________________                          ______________

  8 __________________________  ________________________________________________                          ______________ 

Step 3:  Tell us about your real property  
     Attach additional sheets in the same format, if necessary.
                         A                                                B                C                                                                                                         D
     Brief description of property                                Type of ownership      Physical address                                                                                            County

 9 _ ____________________________________                         ___________________ ___________________________________________                                                                   ________________

 10 _ ____________________________________                        ___________________ ___________________________________________                                                                   ________________

Step 4:  Tell us if bankruptcy is pending

11  Are foreclosure, bankruptcy, receivership, or assignment for  benefit of creditors proceedings pending?   ____yes  ____no 

12  Bankruptcy number ____________________________________

13  Date filed ___  ___/___  ___ /___  ___  ___  ___                                     
                            Month         Day                Year 

                                                                                                                                                                                     Continue to next page....  
EG-13-B front (R-5/12)  

Step 5:  Complete the following statement of assets and liabilities
                                 A              B             C                D                       E                                                              F        G
                                                             Amount of         Monthly                                                                                Date of  Date of    
                                 Present      Liabilities    equity or asset   payment                                                                                first    final  
Description                       value      Balance due    (Col. A minus B)   amount          Pledgee or obligee                                                     payment  payment
 14   Bank accounts             _________    _________       _________        _________      __________________                                                      ________  ________ 
15    Accounts/notes receivable  _________   _________       _________        _________      __________________                                                      ________  ________
16  Merchandise inventory       _________    _________       _________        _________      __________________                                                      ________  ________
17  Machinery and equipment     _________    _________       _________        _________      __________________                                                      ________  ________
18  Real property               _________    _________       _________        _________      __________________                                                      ________  ________
19    Vehicles (model/year)
  a  ___________________        _________    _________       _________        _________      __________________                                                      ________  ________    
   ___________________b         _________    _________       _________        _________      __________________                                                      ________  ________   
20  Other assets (describe)
  a  ___________________        _________    _________       _________        _________      __________________                                                      ________  ________    
   ___________________b         _________    _________       _________        _________      __________________                                                      ________  ________   
21    Federal taxes outstanding _________    _________       _________        _________      __________________                                                      ________  ________
 22  Accounts/notes payable     _________    _________       _________        _________      __________________                                                      ________  ________
23    Other (include judgments)
  a  ___________________        _________    _________       _________        _________      __________________                                                      ________  ________    
   ___________________b         _________    _________       _________        _________      __________________                                                      ________  ________   
 24  Total                      _________    _________       _________        _________                  

Step 6:  Complete the following monthly income and expense summary
                           Monthly income                                                           Monthly expenses                                                         
              Source                               Amount                          Expense                                                                                  Amount 
 
25   Net receipts from sales, services, etc.  ____________________          29 Rent (not included in Line 18)                                                        ___________________  
26   Net rental income                       ____________________           30 Net wages and salaries                                                                           
27   Other income (specify)                                                    (no. of employees_____)                                                               ___________________  
       _________________                     ____________________           31 Materials purchased                                                                   ___________________
       _________________                     ____________________           32 Repairs and maintenance                                                               ___________________
       _________________                     ____________________  33 Supplies                                                                                       ___________________
       _________________                     ____________________           34 Monthly pmts. from Line 24, Column D                                                  ___________________  
       _________________                     ____________________           35 Utilities/telephone                                                                   ___________________  
       _________________                     ____________________           36 Gasoline/oil                                                                          ___________________  
       _________________                     ____________________           37 Insurance                                                                             ___________________  
       _________________                     ____________________           38 Current taxes                                                                         ___________________  
       _________________                     ____________________           39 Other (specify)_________________                                                      ___________________ 
       _________________                     ____________________             _____________________________                                                          ___________________  
       _________________                     ____________________             _____________________________                                                          ___________________
 28   Add Lines 25 through 27.                                              40 Add Lines 29 through 39.                                                                                   
     This amount is your total net income.   ____________________             This amount is your total expenses.                                                    ___________________
 41  Subtract Line 40 from Line 28. This amount is your net income after expenses.                                                                41  ___________________ 

Step 7:  Sign below
Under penalties of perjury, I state that this statement of assets and liabilities and other information is, to the best of my knowledge, true, 
correct, and complete.

Signature______________________________________ Title____________________________ Date ___  ___/___  ___/___  ___  ___  ___

                        This form is authorized as outlined by the Illinois Income Tax Act and the Retailers’ Occupation and related occupation taxes and fees acts.  
EG-13-B back (R-5/12)  Disclosure of this information is REQUIRED. Failure to provide information could result in this form not being processed. 
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