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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 .
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COMMISSIONER OF INSURANCE ·INDUSTRIAL LOAN COMMISSIONER·SAFETY FIRE COMMISSIONER·COMPTROLLER GENERAL OFFICE OF COMMISSIONER OF INSURANCE Ralph T. Hudgens, Commissioner www.oci.ga.gov 2 Martin Luther King Jr., Dr., Suite 604, West Tower, Atlanta, GA 30334 Phone: 404-656-7556 Fax: 770-344-5798 E-mail: TBrewster@oci.ga.gov NON-TRADITIONAL ENTITIES FINANCIAL STATEMENT GID-056 -NT FEB11 (same as GID-056 -EN) DATE NAME OF COMPANY CURRENT ASSETS: 1. 2. 3. Cash (Schedule A) Investments Receivables Fees Receivable a) b) Other Receivable c) Totals Receivable d) Less: Allowance for Uncollectible Net Receivables e) Expenses Other Current Assets Total Current Assets Current Year 12/31/ Last Year 12/31/ 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. This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 - Phone 404-656-2056. Page 1 American LegalNet, Inc. www.FormsWorkFlow.com COMMISSIONER OF INSURANCE ·INDUSTRIAL LOAN COMMISSIONER·SAFETY FIRE COMMISSIONER·COMPTROLLER GENERAL OFFICE OF COMMISSIONER OF INSURANCE Ralph T. Hudgens, Commissioner www.oci.ga.gov 2 Martin Luther King Jr., Dr., Suite 604, West Tower, Atlanta, GA 30334 Phone: 404-656-7556 Fax: 770-344-5798 E-mail: TBrewster@oci.ga.gov NON-TRADITIONAL ENTITIES FINANCIAL STATEMENT GID-056 -NT FEB11 (same as GID-056 -EN) DATE NAME OF COMPANY 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 To Officers and Stockholders c) d) Other Notes Payable Total Notes Payable e) 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. This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 - Phone 404-656-2056. Page 2 American LegalNet, Inc. www.FormsWorkFlow.com COMMISSIONER OF INSURANCE ·INDUSTRIAL LOAN COMMISSIONER·SAFETY FIRE COMMISSIONER·COMPTROLLER GENERAL OFFICE OF COMMISSIONER OF INSURANCE Ralph T. Hudgens, Commissioner www.oci.ga.gov 2 Martin Luther King Jr., Dr., Suite 604, West Tower, Atlanta, GA 30334 Phone: 404-656-7556 Fax: 770-344-5798 E-mail: TBrewster@oci.ga.gov NON-TRADITIONAL ENTITIES FINANCIAL STATEMENT STATEMENT OF OPERATIONS AND RETAINED EARNINGS GID-056 -NT FEB11 (same as GID-056 -EN) NAME OF COMPANY DATE INCOME Current Year 12/31/ Last 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. 13. 14. Net Income Retained Earnings, December 31st Previous Year Less: Distributions to Stockholders $ $ RETAINED EARNINGS, DECEMBER 31, CURRENT YEAR Details of items 4 must be attached. NOTE: This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 - Phone 404-656-2056. Page 3 American LegalNet, Inc. www.FormsWorkFlow.com COMMISSIONER OF INSURANCE ·INDUSTRIAL LOAN COMMISSIONER·SAFETY FIRE COMMISSIONER·COMPTROLLER GENERAL OFFICE OF COMMISSIONER OF INSURANCE Ralph T. Hudgens, Commissioner www.oci.ga.gov 2 Martin Luther King Jr., Dr., Suite 604, West Tower, Atlanta, GA 30334 Phone: 404-656-7556 Fax: 770-344-5798 E-mail: TBrewster@oci.ga.gov NON-TRADITIONAL ENTITIES FINANCIAL STATEMENT GID-056 -NT FEB11 (same as GID-056 -EN) DATE NAME OF COMPANY 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 $ $ $ $ $ $ $ $ $ $ Total Cash On Deposit Cash On Hand (Petty Cash) Total Cash (Line 1, Page 1, Current Year) *D = Demand , T = Time, C = Cash $ $ $ This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 - Phone 404-656-2056. Page 4 American LegalNet, Inc. www.FormsWorkFlow.com COMMISSIONER OF INSURANCE ·INDUSTRIAL LOAN COMMISSIONER·SAFETY FIRE COMMISSIONER·COMPTROLLER GENERAL OFFICE OF COMMISSIONER OF INSURANCE Ralph T. Hudgens, Commissioner www.oci.ga.gov 2 Martin Luther King Jr., Dr., Suite 604, West Tower, Atlanta, GA 30334 Phone: 404-656-7556 Fax: 770-344-5798 E-mail: TBrewst
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