Financial Wind Down Form

FINANCIAL WIND DOWN FORM

Entity Identification

Wind Down Overview

Effective Wind Down Date:

Reason for Wind Down:

Appointed Wind Down Officer / Responsible Individual:

Assets (Estimated)

List primary assets to be realized during wind down. Provide estimated gross value and current custodian.

Liabilities & Claims (Known)

List known creditors, priority, and outstanding balances. Attach additional schedules as necessary.

Disposition & Distribution Plan

State the proposed order and methodology for settling liabilities and distributing residual assets.

Final Bank Accounts and Payment Instructions

Bank to receive proceeds (if applicable)

Tax Filings & Regulatory Compliance

Indicate responsibility for final tax returns, notices to authorities, and required filings. The undersigned certifies that all known payroll, sales, and other statutory obligations will be addressed in accordance with applicable law prior to final dissolution.

Certifications & Representations

By signing below, the signing officers certify under penalty of perjury that:

• The information provided herein is complete and accurate to the best of their knowledge;
• The entity has undertaken reasonable efforts to identify and notify known creditors and claimants;
• The wind down will be conducted in accordance with applicable law and fiduciary duties; and
• The appointed Wind Down Officer is authorized to take actions necessary to settle obligations, collect or transfer assets, make distributions, and execute required final filings on behalf of the entity.

Board Approval

Has the board of directors or equivalent governing body approved this wind down plan? Yes No

Date of Board Resolution:

Attachments

List and attach any schedules, creditor lists, asset appraisals, or legal opinions relied upon in preparing this form.

Declaration

The undersigned declares that they are duly authorized to execute this Financial Wind Down Form on behalf of the entity identified above and that this document constitutes an accurate statement of the wind down plan as approved by the entity's governance.

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