Personal Financial Statement Template - Surety Solutions
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1
2OMB APPROVAL NO. 3245-0188
EXPIRATION DATE:11/30/2004
PERSONAL FINANCIAL STATEMENT
As of
,
U.S. SMALL BUSINESS ADMINISTRATION
Complete this form for: (1) each proprietor, or (2) each limited partner who owns 20% or more interest and each general partner, or (3) each stockholder owning
20% or more of voting stock, or (4) any person or entity providing a guaranty on the loan.
Name
Business Phone
Residence Address
Residence Phone
City, State, & Zip Code
Business Name of Applicant/Borrower
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)
Accounts & Notes Receivable
$
Installment Account (Auto)
$
Life Insurance-Cash Surrender Value Only
Mo. Payments
$
$
(Complete Section 8)
Installment Account (Other)
$
$
Stocks and Bonds
Mo. Payments
$
(Describe in Section 3)
$
Loan on Life Insurance
$
$
Mortgages on Real Estate
Real Estate
(Describe in Section 4)
(Describe in Section 4)
$
$
Automobile-Present Value
Unpaid Taxes
$
Other Personal Property
(Describe in Section 6)
(Describe in Section 5)
Other Liabilities
$
Other Assets
$
(Describe in Section 7)
$
(Describe in Section 5)
Total Liabilities
$
Net Worth
$
$
Total
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 need not be disclosed in "Other Income" unless 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 (3-00) Previous Editions Obsolete
(tumble)
This form was electronically produced by Elite Federal Forms, Inc.
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