BALANCE SHEET
Supplemental Schedule
GENERAL INFORMATION
The Balance Sheet Supplemental Schedule provides detailed financial information necessary for this Department to
assess your financial condition. Compiling this detailed information is necessary in order to be able to complete the Balance
Sheet, LIC 403. Accordingly, this two page form is to be completed prior to completing the Balance Sheet. If the
applicant/licensee files more than one Balance Sheet, an additional Balance Sheet Supplemental Schedule, LIC 403a, must be
completed. The effective date for the information contained on both the LIC 403 and LIC 403a must be the same date and
should be the most current date possible.
All reported information is subject to verification. Accordingly, additional documentation may be requested to support
some or all reported items.
INSTRUCTIONS
At the top of the page include the 1) current date (the information reflected on the Balance Sheet will be as of the date
indicated here), 2) entity name (this is the sole proprietor, partner, partnership or corporate name for whom the information is
being reported), and 3) facility name.
CURRENT ASSETS
Cash in Checking Accounts
List the names and addresses of all financial institutions in which you maintain checking accounts and report the
corresponding account balances. Transfer line 4 “Total” to LIC 403, line 2.
Savings, CD’s and Other Like Accounts
List the names and addresses of all financial institutions in which you have an active savings, CD account or other
form of cash (i.e. Treasury Note) and corresponding balances. Transfer line 7 “Total” to LIC 403, line 3.
Short Term Receivables & Notes
List the name(s) from whom the receivable or note is due, and the type of receivable or note and report the
corresponding amount of each item. Transfer line 10 “Total” to LIC 403, Line 4.
Stocks & Bonds
List the name, corresponding number of shares, price and date or price quote of all stocks, bonds, and other
securities. Transfer line 13 “Total” to LIC 403, line 5.
Other Current Assets
List the type, location and corresponding amounts for all other assets by type. Transfer line 18 “Total” to LIC 403,
line 6.
LONG TERM ASSETS
Report where appropriate, assets at net book value (i.e., purchase price plus improvements less
depreciation).
Real Property
List property type, date acquired, location, and corresponding cost at time of purchase or the current market value
(market value exceeding cost may only be used if appropriate supporting documentation, such as a recent
appraisal, is attached). If market value is used then show the cost in the adjacent column. Transfer line 23 “Total” to
LIC 403, line 8.
Land (Not Included Above)
For land not included under “Real Property” list the date acquired, location and corresponding cost at time of
purchase or the current market value (market value exceeding cost may only be used if appropriate supporting
documentation, such as a recent appraisal, is attached). If market value is used then show the cost in the adjacent
column. Transfer line 26 “Total” to LIC 403, line 9.
All Other Long Term Assets
For long term assets not previously reported above, list type, date acquired, location, and corresponding cost at
time of purchase or the current market value (market value exceeding cost may only be used if appropriate
supporting documentation is attached, such as a current appraisal). If market value is used then show the cost in
the adjacent column. Transfer line 29 “Total” to LIC 403, line 13.
Instructions continued on back of page 2
LIC 403A (9/11)
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