Personal Financial Statement Template

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WORLD WIDE BONDING AGENCY
2846 WILLIAM STREET, BUFFALO, NEW YORK 14227
PERSONAL FINANCIAL STATEMENT
PH 888-681-7685
FAX 716-681-7683
Agent ________________________________________________________________________________________ Bond No. ___________________
Use of company financial statement forms is not mandatory. They are made available as guides to the type of information needed. Signed statements
on comparable bank forms, or on your accountant’s letterhead, are equally acceptable under most circumstances. Fiscal or year end statements are
preferred. Schedules should be completed where they are meaningful. When in doubt, ask your agent about the company’s specific requirements for
the type of credit which you need.
PERSONAL FINANCIAL STATEMENT
Financial statement of
(Name)
(Street Address, City, State, ZIP)
FINANCIAL CONDITION AS OF ___________________________, 20 ___________
ASSETS
AMT(S) ONLY
LIABILITIES
AMT(S) ONLY
Cash on Hand
NOTES PAYABLE TO BANKS
Cash in following Banks (name & address):
name & address): ..........................................................
................................................................................................
.........................................................................................
................................................................................................
OTHER NOTES AND ACCOUNTS PAYABLE
STOCKS AND BONDS
Listed (Schedule 1).................................................................
Real Estate Loans (Schedule 4)......................................
Unlisted (Schedule 1) .............................................................
Sales Contracts & Sec. Agreements (Schedule 5)..........
Loans on Life Insurance Policies (Schedule 6) ...............
REAL ESTATE
Improved (Schedule 4) ...........................................................
TAXES PAYABLE
Current Year Income Taxes Unpaid ................................
Unimproved (Schedule 4).......................................................
Prior Year Income Taxes Unpaid ....................................
Trust Deeds & Mortgages (Schedule 3) .................................
Real Estate Taxes Unpaid ...............................................
LIFE INSURANCE
Cast Surrender Value (Schedule 6)........................................
OTHER LIABILITIES
Unpaid Interest ................................................................
ACCOUNTS AND NOTES RECEIVABLE
Relatives and Friends (Schedule 2/3) ....................................
Other (Itemize).................................................................
.........................................................................................
Other (Schedule 2/3) ..............................................................
.........................................................................................
Doubtful (Schedule 2/3)..........................................................
TOTAL LIABILITIES ........................................................
OTHER PERSONAL PROPERTY
Automobile (Schedule 5) ........................................................
NET WORTH ...................................................................
Other (Itemize, Schedule 5)....................................................
TOTAL
TOTAL
(Refer to Federal Income Tax
(Refer to Federal Income Tax
ANNUAL INCOME
ANNUAL EXPENDITURES
Returns for Previous Year)
Returns for Previous Year)
SALARY OR WAGES ................................................................
PROPERTY TAXES AND ASSESSMENTS.......................
DIVIDENDS AND INTEREST ....................................................
FEDERAL AND STATE INCOME TAXES ..........................
RENTALS (GROSS) ..................................................................
REAL ESTATE LOAN PAYMENTS ....................................
BUSINESS OR PROFESSIONAL INCOME (NET) ...................
PAYMENTS ON CONTRACTS & OTHER NOTES ............
OTHER INCOME (DESCRIBE) .................................................
INSURANCE PREMIUMS...................................................
ESTIMATED LIVING EXPENSES ......................................
OTHER
TOTAL INCOME
TOTAL INCOME
To assist the Surety in its evaluation of the above Statement, I hereby certify that all material facts relating to the following conditions are set forth in the attached exhibit(s)
incorporated herein by reference: Contingent liabilities as endorser, co-maker or guarantor $____________________________
Contingent liabilities on leases or contracts $____________________________; pledge or hypothecation of assets $____________________________;
Legal Claims $____________________________; Tax Liens $____________________________
(S)
ID-1256 (REV. 9/00) • PAGE 1 of 2
CONFIDENTIAL

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