FORM 5 (6/92)
MONTHLY CASH STATEMENT
Debtor: ________________________ Statement for the period:
Case #: ________________________ From: _________ To: ________
Cash Activity Analysis (Cash Basis Only):
General Payroll Tax Cash Coll.
Acct. Acct. Acct. Acct.
A. Beginning Balances _______ _______ _______ ______
B. Receipts
(Attach separate schedule) _______ _______ _______ _______
C. Balance Available
(A + B): _______ _______ _______ _______
D. Less Disbursements
(Attach separate schedule) _______ _______ _______ _______
E. ENDING BALANCE
(C - D) _______ _______ _______ _______
(PLEASE ATTACH COPIES OF MOST RECENT RECONCILED BANK STATEMENTS FROM
EACH ACCOUNT)
General Account:
1. Depository Name & Location _____________________________
2. Account Number _____________________________
Payroll Account:
1. Depository Name & Location _____________________________
2. Account Number _____________________________
Tax Account:
1. Depository Name & Location _____________________________
2. Account Number _____________________________
Other monies on hand (specify type and location)(i.e., CD's
petty cash): _____________________________________________________________
___________________________________________________________________________
Date: ______________ ____________________________
Debtor in Possession