Assets
Liablities
Cash on
Hand & Banks
Accounts
Payable
Savings
Account
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
Real
Estate
Mortgages
on 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)
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.
Section
2. Notes Payable to Banks and Others.
(Use attachments if necessary. Each
attachment must be identified as a part
of this statement and signed.)
Section
3. Stocks and Bonds. (Use attachments if
necessary. Each attachment must be
identified as a part of this statement
and signed).
Section
5. Other Personal Property and Other
Assets. (Describe, and if any is pledged
as security, state name and address of
lien holder, amount of lien, termsof
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
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
a loan or guaranteeing a loan. I
understand FALSE statements may result
in forfeiture of benefits and possible
prosecution by
