Personal Financial Statement Form Bfl Canada
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PERSONAL FINANCIAL STATEMENT FORM
To induce Aviva Insurance Company of Canada to become Surety for the Undersigned, or to accept the Undersigned as Indemnitor.
Name of Individual:
(print or type)
Home Address:
Date of Birth:
/
/
Drivers Licence No.
SIN
-
- _______
dd
mm
yy
In Reference to
A: Bond Number:
OR
B: Bond Facility:
PERSONAL ASSETS
$ VALUE
PERSONAL LIABILITIES
$ VALUE
Cash
$
Due to Banks
$
Shares, Investments, Etc
$
Personal Income Tax Due
$
Accounts Receivable
$
Other Taxes Payable
$
Personal Real Estate
$
Accounts Payable
$
Due Against Real Estate
$
Other Personal Assets
1.
$
Debt on Other Assets
1.
$
2.
$
2.
$
3.
$
3.
$
TOTAL PERSONAL ASSETS
$
TOTAL PERSONAL LIABILITIES
$
A. Gross Income from all business activities:$
B. Gross Income from all other sources:$
C. Have you ever failed in business, or compromised with creditors? Yes
No
If Yes, please explain:
D. Lines of Business in which you are engaged:
E.
Do you have a personal line of bank credit established?
Yes
No
If Yes, Amount: $
F.
Are you now, or do you plan to assume contingent liability such as endorser, indemnitor, guarantor, personal Surety for an individual,
individuals or corporations, partnerships or co-partnerships?
Yes
No
If Yes, please explain:
Amount of liability assumed: $
Date liability assumed:
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