Commonwealth of Virginia
Department of Professional and Occupational Regulation
9960 Mayland Drive, Suite 400
Richmond, Virginia 23233-1485
(804) 367-8511
www.dpor.virginia.gov Board for Contractors
FINANCIAL STATEMENT
A501-27FINST-v6 Board for Contractor/FIN ST APP
07/01/2017 Page 1 of 1
ONLY CLASS A & CLASS B APPLICANTS MUST COMPLETE EITHER
THIS FINANCIAL STATEMENT OR THE SURETY BOND FORM (NOT BOTH).
Applicants are required to furnish proof of financial responsibility. Excluding any property owned as tenants by the entirely, applicants for a Class A
license must document a net worth or equity of $45,000 and Class B license applicants must document a net worth or equity of at least $15,000.
All ASSETS and LIABILITIES must be for the firm applying for the license and must be in the company name. Financial information reported
must not be more than one year old. Verification of each line item may be requested when the application is reviewed (unless a CPA review/audit is
submitted, as provided below).
Instead of using this form, applicants may substitute a current financial statement that duplicates the information below only if it includes the
signature statement listed on this form and is signed by the preparer. The board will accept a CPA review or audit in lieu of the financial statement,
without requiring additional independent verification.
Effective Balance Sheet as of
(MM/DD/YYYY)
Contracting Business Name
ASSETS
1.
Current Assets
2. Cash and Investments**
3. Accounts Receivable (Net)
4. Inventories
5. Prepaid Expenses
6. Other Current Assets
7. Total Current Assets (sum of lines 2 through 6)
8. Land, Buildings and Equipment (Net) **
9. Other Non-Current Assets **
10. TOTAL ASSETS (sum of lines 7 through 9)
** Items in these categories
require documentation for
independent verification
unless a CPA review or
audit is submitted. This
includes bank statements,
titles, deeds, etc. and may
delay processing of your
application.
LIABILITIES AND OWNER'S EQUITY
11.
Current Liabilities
12. Accounts Payable
13. Current Portion of Long Term Debt (payable within the next 12 months)
14. Accrued Taxes
15. Accrued Payroll
16. Other Current Liabilities
17.
Total Current Liabilities (sum of lines 12 through 16)
18. Long-term Debt
19. Other Long-term Liabilities
20.
Total Liabilities (sum of lines 17 through 19)
21. OWNER'S EQUITY (NET WORTH) (line 10 minus line 20)
22. TOTAL LIABILITIES & OWNER'S EQUITY (sum of lines 20 and 21)
Is a substitute Financial
Statement Attached?
No
Yes
Signature of Financial Statement Preparer
Signature
Printed Name
To the best of my knowledge, this financial statement accurately represents the firm's financial position as of the date
indicated and the current financial position is essentially as good, or better than shown in the furnished statement.
Date
Title
