Form Com/att007-3 - Occupation Record And Financial Statement Of Individual License Applicant Page 2

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II. Personal financial statement - List below your personal assets and liabilities. Include real estate, bank deposits,
stock, bonds, personal property, loans, mortgages, etc. If none, so state.
Describe assets
Amount
$
Total assets
$
Describe liabilities
Amount
$
$
Total liabilities
III.
Personal investment in business
(a)
Amount to be invested by applicant:
Cash
$
Equipment
$
Goodwill
$
Other
$
Total $
(b)
Is applicant’s investment in business to be financed solely from assets listed in Part II above?
Yes
No
(c)
If “No” to “b”, list below the amount of additional monies to be invested in the business, the source of same and
the name and address of any person who has undertaken or will undertake to advance monies to the applicant to
assist in financing said business and the relationship, if any, of each person to the applicant.
Amount
Source
Name
Address
Relationship
The applicant whose signature appears below represents under penalty of perjury that the foregoing statements are
true and agrees that they shall be made a part of the application for a license. It is understood that information reported may
be used for background investigation pursuant to Section 10-201 of Article 2B of the Annotated Code of Maryland.
Date
Signature of applicant

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