Personal Financial Statement - Women Owned Small Business (Wosb) Program
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4OMB APPROVAL NO.: 3245-0188
EXPIRATION DATE: 01/31/2018
PERSONAL FINANCIAL STATEMENT
WOMEN OWNED SMALL BUSINESS (WOSB) PROGRAM
U.S. SMALL BUSINESS ADMINISTRATION
This form must be completed by each individual claiming economic disadvantage in connection with the SBA’s Women-Owned Small Business (WOSB) Program. A
separate form must be completed by the individual’s spouse, unless the individual and the spouse are legally separated. Use attachments if necessary. Each attachment
must be identified as a part of this statement and signed. In addition, each individual claiming economic disadvantage must update the form as changes arise, but at least
annually, to ensure the information is current, accurate and complete.
SBA’s regulations state that to be considered economically disadvantaged for purposes of the WOSB Program, a woman must have an adjusted gross income averaged
over the three prior fiscal years of $350,000 or less; less than $6 million in the fair market value of all her assets (to include her primary residence and value of the
business concern); and less than $750,000 in personal net worth (excluding equity interest in her personal residence and ownership interest in the business, and funds
invested in a retirement account that are unavailable until retirement age). 13 C.F.R. §127.203.
Forms must be uploaded to the WOSB Program Repository. For more information on the WOSB program and the repository,
visit
Name:
Business Phone:
Business Name and Address:
Other Phone:
City, State, & Zip Code:
The Information is current as of [month/day/year]:
Business Type:
__________Corporation
_________S Corp.
________LLC
______Partnership
_____ Sole Proprietor
Married: ______Yes _____No
ASSETS
LIABILITIES
(Omit Cents)
(Omit Cents)
Cash on Hand & in banks…………………………$ ________________
Accounts Payable……………………………$ ______________
Savings Accounts…………………………………..$ ________________
Notes Payable to Banks and Others……….$ ______________
IRA or Other Retirement Account………………...$ ________________
(Describe in Section 2)
(Describe in Section 5)
Installment Account (Auto)…………………..$ ______________
Accounts & Notes Receivable…………………….$ ________________
Mo. Payments
$ ___________
(Describe in Section 5)
Installment Account (Other)………………....$ ______________
Life Insurance – Cash Surrender Value Only……$ ________________
Mo. Payments
$ ___________
(Describe in Section 8)
Loan(s) Against Life Insurance……………...$ ______________
Stocks and Bonds…………………………………..$ ________________
Mortgages on Real Estate…………………...$ ______________
(Describe in Section 3)
(Describe in Section 4)
Real Estate…………………………………………..$ ________________
Unpaid Taxes………………………………….$ _____________
(Describe in Section 4)
(Describe in Section 6)
Automobiles…………………………………………$ ________________
Other Liabilities………………………………..$ _____________
(Describe in Section 5, and include
(Describe in Section 7)
Year/Make/Model)
Total Liabilities………………………………....$ _____________
Other Personal Property……………………………$ ________________
Net Worth……………………………………….$ _____________
(Describe in Section 5)
Other Assets………………………………………….$ _______________
Total
$ _____________
(Describe in Section 5)
*Must equal total in assets column.
Total
$ ________________
Section 1.
Source of Income.
Contingent Liabilities
Salary………………………………………………….$ ________________
As Endorser or Co-Maker…………………….$ _____________
Net Investment Income……………………………...$ ________________
Legal Claims & Judgments…………………..$ _____________
Real Estate Income………………………………….$ ________________
Provision for Federal Income Tax…………....$_____________
Other Income (Describe below)*…………………...$ ________________
Other Special Debt…………………………….$ _____________
Description of Other Income in Section 1.
*Alimony or child support payments should not be disclosed in “Other Income” unless it is desired to have such payments counted toward total income.
SBA Form 413 (WOSB) (09-14) Previous Editions Obsolete
Page 1
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