Fillable Personal Financial Statement Template - Surety Solutions (Page 2 of 2) in pdf

Personal Financial Statement Template - Surety Solutions Page 2

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Section 3. Stocks and Bonds. (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed).

Market Value

Date of

Number of Shares

Name of Securities

Cost

Total Value

Quotation/Exchange Quotation/Exchange

(List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part

Section 4. Real Estate Owned.

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 insurance company and beneficiaries)

I authorize SBA/Lender to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify the above

I certify the above and the statements contained in the attachments are true and accurate as of the stated date(s). The statements are made for the

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 obtaining

purpose of either obtaining surety credit or insurance. I understand that FALSE statements may result in the forfeiture of benefits and possible prosecution

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

by the U.S. Attorney General (Reference 18 U.S.C. 1001).

(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

Please Note: This form must be filled out in its entirety and should not contain any blank sections. Please write "N/A" if a

concerning this estimate or any other aspect of this information, please contact Chief, Administrative Branch, U.S. Small Business