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Third Party Administrator Financial Statement GID-56 - Georgia

Third Party Administrator Financial Statement Form. This is a Georgia form and can be used in Insurance And Safety Fire Commissioner Statewide .
 Fillable pdf Last Modified 2/2/2010
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JOHN W. OXENDINE COMMISSIONER OF INSURANCE SAFETY FIRE COMMISSIONER INDUSTRIAL LOAN COMMISSIONER COMPTROLLER GENERAL SEVENTH FLOOR, WEST TOWER FLOYD BUILDING 2 MARTIN LUTHER KING JR. DR. ATLANTA, GA 30334 (404) 656-2056 TDD#(404) 656-4031 Rev No: 11/01 Form No: GID-56 OFFICE OF INSURANCE AND SAFETY FIRE COMMISSIONER THIRD PARTY ADMINISTRATOR FINANCIAL STATEMENT NAME OF COMPANY__________________________________________________________ DATE________________ Current Year (12/31/____) Last Year (12/31/______) CURRENT ASSETS: 1. 2. 3. Cash (Schedule A) _____________________ Investments _____________________ Receivables _____________________ a) Fees Receivable _____________ _____________________ b) Other Receivable _____________ c) Totals Receivable _____________ d) Less: Allowance for Uncollectables _____________ e) Net Receivables _____________________ Expenses _____________________ Other Current Assets _____________________ Total Current Assets _____________________ _____________________ ____________________ _____________________ _____________________ 4. 5. 6. _____________________ _____________________ _____________________ _____________________ NON-CURRENT ASSETS: 7. 8. 9. 10. 11. Investments Receivables Organization Expenses Other Non-Current Assets Total Non-Current Assets _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ FIXED ASSETS: 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. Office Furnishings and Equipment Automobiles Total Furn.,Equip. and Autos Less: Accumulated Depreciation Net Furn., Equip. and Autos Leasehold Improvements Less: Accumulated Amortization Net Leasehold Improvements Real Estate Less: Accumulated Depreciation Net Real Estate Other ___________________ (Identify) Total Fixed Assets TOTAL ASSETS ________________ ________________ ________________ ________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ $____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ $____________________ NOTE: Details of items 3b, 4, 5, 7, 8, 10, and 23 must be attached. GID-56/Page 1 of 6 American LegalNet, Inc. www.FormsWorkflow.com THIRD PARTY ADMINISTRATOR FINANCIAL STATEMENT NAME OF COMPANY ___________________________________________________________DATE_______________ CURRENT LIABILITIES: 1. Accounts Payable: a) Trade b) Other c) Total Accounts Payable Fees Payable Taxes Payable Notes Payable : a) To Financial Institutions b) Real Estates Mortgages c) To Officers and Stockholders d) Other Notes Payable e) Total Notes Payable Accrued Interest Payable Other Current Liabilities Total Current Liabilities Current Year (12/31/___) _____________________ ________________ ________________ _____________________ _____________________ _____________________ ________________ ________________ ________________ ________________ ________________ _____________________ _____________________ _____________________ Last Year(12/31/____) _____________________ 2. 3. 4. _____________________ _____________________ _____________________ 5. 6. 7. _____________________ _____________________ _____________________ LONG TERMS LIABILITIES: 8. Notes and Loans Payable a) To Financial Institutions ________________ b) Real Estates Mortgages ________________ c) To Officers and stockholders ________________ d) Other Notes & Loans Payable ________________ e) Total Notes & Loans Payable ________________ Other Long-Term Liabilities _____________________ Total Long Term Liabilities _____________________ Total Liabilities _____________________ 9. 10. 11. _____________________ _____________________ _____________________ NET WORTH: 12. Capital Stock a) Common b) Preferred c) Total Capital Stock Capital Paid-In Retained Earnings Less: Treasury Stock NET WORTH TOTAL LIABILITIES & NET WORTH 13. 14. 15. 16. 17. ________________ ________________ ________________ ________________ ________________ ________________ _____________________ $____________________ _____________________ $____________________ NOTE: Details of items 1a, 1b, 2, 4a, b, c, d, 5, 6, 8a, b, c, d and 9 must be attached. GID-56/Page 2 of 6 American LegalNet, Inc. www.FormsWorkflow.com THIRD PARTY ADMINISTRATOR FINANCIAL STATEMENT NAME OF COMPANY DATE STATEMENT OF OPERATIONS AND RETAINED EARNINGS INCOME For the Period Ending Last Year 12/31/ ___________________ ___________________ ___________________ ___________________ Current Year 12/31/ 1. 2. 3. 4. 5. Earned Fees Net Investment Income Earned ___________________ ___________________ Net Realized Capital Gains (or Losses) ___________________ All Other Income* Total Income ___________________ EXPENSES 6. 7. 8. 9. 10. Fees Paid Salaries General Expenses Total Operating Expenses Federal and State Income Taxes ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ NET INCOME AND RETAINED EARNINGS 11. 12. Net Income Retained Earnings, December 31st Previous Year Less: Distributions to Stockholders ____________________ ____________________ ____________________ 13. 14. RETAINED EARNINGS, DECEMBER 31, CURRENT YEAR $ ___________________ $_________________ Details of items 4 must be attached. NOTE: GID-56/Page 3 of 6 American LegalNet, Inc. www.FormsWorkflow.com THIRD PARTY ADMINISTRATOR FINANCIAL STATEMENT NAME OF COMPANY ______________________________________________________ DATE ___________________ SCHEDULE A CASH ON HAND AND ON DEPOSIT List all accounts and locations of Cash on Hand. Place an asterisk (*) in the D/T/C/* column if all or any part of the deposit balance is assigned as collateral for a loan or is otherwise pledged or restricted. Attach supporting statement with explanation of pledge or restriction. Name and address of Depository Account Number D/T/C* Balance __________________________________________ _____________________ ______ $__________________________ __________________________________________ _____________________ ______ $__________________________ ________________
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