Personal Financial Statement Form

Personal Financial Statement Form.pdf Use this to show your all types of your accumulated income. Download

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OMB APPROVAL NO. 3245-0188 
EXPIRATION DATE: 8/31/2011 	
PERSONAL FINANCIAL STATEMENT 	
U.S. SMALL BUSINESS ADMINISTRATION  As of 
, 	
Complete this form for: (1) each proprietor, or (2) each limited par\
tner who owns 20% or more interest and each general partner, or (3) each stockhol\
der owning

20% or more of voting stock, or (4) any person or entity providing a g\
uaranty on the loan.

Name 
	
Business Phone 	
Residence Address 	Residence Phone 
City, State, & Zip Code 
Business Name of Applicant/Borrower
	
ASSETS 
Cash on hand & in Banks 
Savings Accounts 
IRA or Other Retirement Account 
Accounts & Notes Receivable 
Life Insurance-Cash Surrender Value Only  (Complete Section 8) 
Stocks and Bonds  (Describe in Section 3) 
Real Estate  (Describe in Section 4) 
Automobile-Present Value 
Other Personal Property  (Describe in Section 5) 
Other Assets  (Describe in Section 5) 	
Total 
Section 1.  Source of Income 	
Salary

Net Investment Income

Real Estate Income

Other Income (Describe below)*

Description of Other Income in Section 1.
 (Omit Cents) 
LIABILITIES 
(Omit Cents) 	
$ 	Accounts Payable 	$ 
$ 	
Notes Payable to Banks and Others 	$ 
$ 	
(Describe in Section 2) 	
$ 	Installment Account (Auto) 	$ 
$ 	
Mo. Payments  $ 
Installment Account (Other) 	
$ 
$ 	
Mo. Payments  $ 
Loan on Life Insurance 	$ 
$ 	
Mortgages on Real Estate 	$ 	
(Describe in Section 4) 	
$ 	Unpaid Taxes 	$ 
$ 	
(Describe in Section 6) 
Other Liabilities 	
$ 
$ 	
(Describe in Section 7) 
Total Liabilities 	$ 	
Net Worth 	$ 
$ 	
Total 	$ 	
Contingent Liabilities 	
$ 	As Endorser or Co-Maker 	$ 
$ 	
Legal Claims & Judgments 	$ 
$ 	
Provision for Federal Income Tax 	$ 
$ 	
Other Special Debt  $ 	
*Alimony or child support payments need not be disclosed in "Other Incom\
e" unle ss it is desired to have such payments counted toward total income. 	
(Use attachments if necessary. Each attachment must be identified as a \
part of this statement and signed.)
Section 2. Notes Payable to Banks and Others. 	
Original  Current Payment  Frequency  How Secured or Endorsed
Name and Address of Noteholder(s)  Balance Balance  Amount (monthly,etc.)  Type of Collateral 	
SBA Form 413 (	10-08) Previous Editions Obsolete 	(tumble) 	This form was electronically produced by Elite Federal Forms, Inc.

Section 3. Stocks and Bonds. (Use attachments if necessary.  Each attachment must be identified as a part of this statement and signed). 
Number of Shares 	Name of Securities 	Cost 	Market Value 	Date of 	Total Value	Quotation/Exchange 	Quotation/Exchange 	
Section 4. Real Estate Owned.		(List each parcel separately. Use attachment if necessary.  Each attachment must be identified as a part 
of this statement and signed.) 	
Property A 	Property B 	Property C 	
Type of Property 
Address 
Date Purchased 
Original Cost 
Present Market Value 
Name &

Address of Mortgage Holder

Mortgage Account Number

Mortgage Balance

Amount of Payment per Month/Year 

Status of Mortgage 	
(Describe, and if any is pledged as security, state name and address of\
 lien holder, amount of lien, terms	
 
Section 5. Other Personal Property and Other Assets. 	
of payment and if delinquent, describe delinquency) 	
Section 6. 
Unpaid Taxes.  (Describe in detail, as to type, to whom payable, when due, amount, and\
 to what property, if any, a tax lien attaches.) 
Section 7. Other Liabilities.  (Describe in detail.) 
Section 8. Life Insurance Held.  (Give face amount and cash surrender value of policies - name of insura\
nce comp any and beneficiaries) 
I authorize SBA/Lender to make inquiries as necessary to verify the accu\
racy of the statements made and to determine my creditworthiness. I certify th\
e above 
and the statements contained in the attachments are true and accurate as\
 of the stated date(s). These statements are made for the purpose of either o\
btaining 
a loan or guaranteeing a loan. I understand FALSE statements may result \
in forfeiture of benefits and possible prosecution by the U.S. Attorney General\
 
(Reference 18 U.S.C. 1001). 
Signature: 	Date: 	Social Security Number: 	
Signature: 	Date: 	Social Security Number: 	
PLEASE NOTE:		The estimated average burden hours for the completion of this form is 1.\
5 hours  per response. If you have questions or comments 
concerning this estimate or any other aspect of this information, please\
 contac t Chief, Administrative Branch, U.S. Small Business 
Administration, Washington, D.C. 20416, and Clearance Officer, Paper Red\
uction Project (3245-0188), Office of Management and Budget, 
Washington, D.C. 20503. PLEASE DO NOT SEND FORMS TO OMB.