Personal Financial Statement

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IMPORTANT: We strongly recommend you go to this link to download a blank version of the form that will be filled as you complete this form. This will enable you to be ready with all of the details and documents needed to accurately complete this form online.

All information provided within this form is accurate as of:*

Must be current within the last 30 days.

U.S. SMALL BUSINESS ADMINISTRATION

Each individual claiming economic disadvantage must submit personal financial information.
When married, an individual claiming economic disadvantage must submit separate financial information for his or her spouse, unless the individual and the spouse are legally separated.
Additionally, any proprietor; partner; member of a limited liability company (LLC); or owner of 10% or more of the equity of the business MUST complete this form.

Note: Please complete this form with Personal Information -- not Business information.

Name*

Name of individual completing form.

Home Address*

City, State, & Zip Code*

Home Phone*

Business Name/Applicant*

Business Phone*

Business UEI / Unique Entity Identifier*

Cash on Hand & In Banks*

The amount in your checking account.

Savings Accounts*

Include the amount in any money market and CD accounts.

IRA or Other Retirement Account *

The value of your IRA or any other retirement accounts in your name -- including 401(k)s.

Roth*

The value you of your Roth IRA.

Describe: IRA or Other Retirement Account and Roth

Life Insurance – Cash Surrender Value Only*

The cash surrender value of a life insurance policy is the cash value that is available to a life insurance policyholder upon early termination of the policy. This does not apply to term life insurance policies. For permanent of whole life insurance policies, the cash surrender value is the cash value of the accumulated investment portion of the policy payable to the policyholder upon cancellation of the policy.

Describe. Life Insurance Held. Give face amount and “Current” cash surrender value of policies – name of insurance company a Beneficiaries

Stocks, Bonds, or Mutual Funds*

Total current market value of all stocks and bonds owned. Provide details below or If you need more space, provide an attachment.

Details: Stocks, Bonds and Mutual Funds. Use attachments if necessary. Each attachment must be identified as part of this statement and signed*

	Number of Shares	Name of Securities	Cost	Market Value Quotation/Exchange	Date of Quotation/Exchange	Total Value

Need more room? Upload attachment if needed to complete the list of stocks, bonds and mutual funds held.

Only provide attachment if you are unable to provide details of all stocks, bonds and mutual funds in the table above.

Real Estate*

List the current fair market value of all commercial or residential real estate you own. Provide details below.

Details: Real Estate Owned. List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part of this statement and signed*

	Property A Primary Residence	Property B	Property C
Type of Real Estate e.g. Primary Residence, Other Residence, Rental Property, Land, etc if jointly owned, please explain
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

Automobiles (value)*

Other Personal Property (value)*

Such as boat, jewelry, etc. Describe below.

Accounts & Notes Receivable*

Any money that you have lent to others. Describe below.

Other Assets*

The value of any other assets you own that don’t fall into the above categories. Describe below.

Describe from Above: (1) Automobiles (List Year/Make/Model), (2) Other Personal Property and (3) Accounts & Notes Receivable (4) Other Assets.*

Provide details for all dollar amounts listed above for Automobiles, Other Personal Property, Accounts & Notes Receivable and Other Assets.

Applicant's Business Equity (in dollars)*

Answer for the firm which is applying for WOSB/EDWOSB certification. The equity of a business is the net difference between a company's total assets and its total liabilities. After making this computation, consider the percentage of the firm you own to determine the dollar amount of your personal business equity.

Equity in Other Firms*

See previous question. Provide dollar amount of equity in other firms in which you are an owner.

Total Assets*

Accounts Payable*

Any debts you owe to another party other than banks, usually on a short-term basis (i.e. 30, 60, or 90 days).

Notes Payable to Banks and Others*

Total of all outstanding balances on your personal credit cards, lines of credit, and business installment loans. Detail below.

Details: Notes Payable to Banks and Others.

	Names and Addresses of Noteholder(s)	Original Balance	Current Balance	Payment Amount	Frequency monthly, etc	How Secured or Endorsed Type of Collateral

Installment Account (Auto)*

Provide the total and monthly payment amount of your balance for any outstanding automobile loans.

Mo. Payments (Auto)*

Current monthly payment on the total of all outstanding automobile loans.

Installment Account Other*

List the total and monthly payment amount of any outstanding personal installment loans including student and personal loans.

Mo. Payments Other*

Current monthly payment on total of all other installment loans.

Loans Against Life Insurance*

Provide the balance of any loans you’ve taken out for which you’ve pledged your life insurance policy as collateral (only if it was whole life insurance).

Mortgages on Real Estate*

The balance of mortgages on real estate you own.

Unpaid Taxes*

Total of any due but unpaid taxes since your most recent filed tax return. Provide details below.

Describe: Unpaid Taxes. Describe in detail as to type, to whom payable, when due, amount, and to what property, if any.

Other Liabilities*

Provide the total amount of any other outstanding debt not listed in the previous sections. Provide details at right.

Details: Other Liabilities.

Total Liabilities*

This field will automatically calculate.

Net Worth*

IMPORTANT: The two fields below should have the exact same total.

Your "Total Liabilities & Networth" should equal your "Total Assets."

Total Liabilities & Net Worth*

Total Assets (from Assets section)*

Salary (monthly)*

Describe below.

Net Investment Income*

Total of any income you earn as dividends and interest from your investments.

Real Estate Income*

Net income (after expenses) you receive from any of your owned real estate properties, i.e. through sale, lease, or rental. Describe below.

Other Income*

*Alimony or child support payments should not be disclosed in “Other Income” unless it is desired to have such payments counted toward total income.

Description of Other Income From Above: (1) Salary, (2) Net Investment Income, (3) Real Estate Income, (4) Other Income*

Contingent Liabilities: As Endorser or Co-Maker*

The total balance of any outstanding debts for which you or your spouse acted as guarantor or co-signer.

Contingent Liabilities: Legal Claims and Judgments*

The total amount you might owe for any pending legal claims or judgments.

Contingent Liabilities: Provisions for Federal Income Tax*

The amount of money you’re setting aside to pay federal taxes for an expected increase in income due to pending litigation, dispute, or asset sale.

Contingent Liabilities: Other Special Debt*

The total amount of any other outstanding contingent debts not listed above.

I authorize the SBA to make inquiries as necessary to verify the accuracy of the statements. CERTIFICATION: (to be completed by person submitting the information requested on this form)

By signing this form, I certify under penalty of criminal prosecution that all information on this form and any additional supporting information submitted with this form is true and complete to the best of my knowledge. I understand that SBA will rely on this information when making decisions regarding an application for participation in the Women-Owned Small Business Federal Contract Program Program.

Any person who misrepresents a business concern’s status as an 8(a) BD Program participant or SDB concern (or EDWOSB), or makes any other false statement in order to influence the 8(a) certification (or EDWOSB) or other review process in any way(e.g., annual review, eligibility review), shall be: (1) subject to fines and imprisonment of up to 5 years, or both, as stated in Title 18 U.S.C. § 1001; (2) subject to fines of up to $500,000 or imprisonment of up to 10 years, or both, as stated in Title 15 U.S.C. § 645; (3) subject to treble damages and civil penalties under the False Claims Act, 31 U.S..C 3729; (4) subject to administrative remedies, including suspension and debarment; and (5) ineligible for participation in programs conducted under the authority of the Small Business Act.

Signature*

Date of Signature*

Date

Print Name*

Social Security No.*

IMPORTANT: If the form does not submit when you click on the green "Submit" button below, this means you have not completed all required fields on the form. Please scroll back up to locate any fields left incomplete before clicking the Submit button below.

PERSONAL FINANCIAL STATEMENT

PERSONAL INFORMATION SECTION

ASSETS

LIABILITIES

SOURCE OF INCOME

CONTINGENT LIABILITIES

AUTHORIZATION AND SIGNATURE

NOTICE TO APPLICANTS OR PARTICIPANTS IN THE 8(a) BD PROGRAM: CRIMINAL PENALTIES AND ADMINISTRATIVE REMEDIES FOR FALSE STATEMENTS