Personal/corporate Financial Statement Page 2
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1
2Other Liabilities (Itemize)
$__________
__________$__________
__________$__________
__________$__________
TOTAL LIABILITIES
$__________
NET WORTH:
Investment/Capital Stock
$__________
Surplus
$__________
Retained Earnings
$__________
TOTAL NET WORTH
$__________
TOTAL LIABILITIES & NET WORTH
$__________
INCOME AND OPERATING EXPENSES
Average Monthly Income (average over past 6 months)
$__________
Average Monthly Expenses (average over past 6 months)
$__________
ADDITIONAL INFORMATION
List the names and addresses of your financial institutions:
1._______________________________________________________________________________________________
2._______________________________________________________________________________________________
3._______________________________________________________________________________________________
4._______________________________________________________________________________________________
Please list and give a brief explanation of all Lawsuits pending or judgments entered against the applicant agency in the last 3
years (attach information if needed)
Does the applicant agency have any debts, obligations, or potential liabilities of the applicant not listed elsewhere on this
application _______yes _______ no
Is the applicant an endorser, co-maker/signer or guarantor on an outstanding liability? ______ yes
______ no
Are any assets of the applicant, including stock, pledged or assigned other than those described? ______ yes
______ no
Has the applicant filed bankruptcy in the last 10 years? ______ yes
______ no
If you answered yes to any of the above questions, please attach additional pages and explain in detail, including
an estimate of the liability or debt where applicable.
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