Personal Financial Statement Form

Name*

First NameLast Name

Date of Birth

Date

SSN

Home Phone Number*

Area CodePhone Number

Personal Email*

example@example.com

Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you receiving public assistance?

	Yes	Amount
Welfare
WIX
Food Stamps
Social Security

Veteran Status

	Yes
Non Veteran
Vietnam Era
Other Veteran
Social Security
Are you a US citizen

If you are not a US citizen, what is your residency status

Financial Information as of:

Date

Annual Income:

	Amount ($)
Salary/Wages
Dividend/Investment Income
Other Business Income
Other Income
Alimony/Child Support
Rental Income
Pension Income
TOTAL ANNUAL INCOME

Annual Expenses:

	Amount ($)
Federal Income Tax
State Income Tax
Residential Mortgage or Rent Payment
Residential Taxes
Home/Auto Insurance
Alimony Child Support
Medical Expenses
Credit Card Payments
Auto Loan Payments
Other Loan Payments
Utilities
TOTAL ANNUAL EXPENSES

Assets:

	Amount ($)
Cash/Checking/Savings
Certificates of Deposit
Investment Accounts
Retirement Accounts
Cash Value Life Insurance
Residential Real Estate
Other Real Estate
Autos
Other Assets (Detail below)
TOTAL ASSETS

Please List Other Assets - ASSET / VALUE / CO-OWNERS

Liabilities:

	Value ($)
Credit Card Balance
Auto Loans
Mortgage Loans
Property Taxes Payable
State/Federal Income Tax Payable
Bills Payable
Life Insurance loans
401 Account Loans
TOTAL LIABILITIES

Total Assets Minus (-) Total Liabilities

Contingent Liabilities:

	Yes	No	Amount
Are you a guarantor on any other loan?
Are there any lawsuits or legal actions against you?
Are your personal taxes past due?
Are your real estate taxes past due?
Do you have past due loans?
Do you have life insurance?

Contingent Liabilities continued:

	Yes	No
Have you ever filed personal bankruptcy?
Have you ever been convicted of a felony?
Do you have health insurance?
Do you have a will?

UPLOAD FILES

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The Quaboag Valley CDC/BAC is an equal opportunity employer, lender and provider and does not discriminate on the basis of age, color, disability, family/parental status, national origin, race, religion, sex, gender identity (including expression), sexual orientation, marital status, income derived from public assistance programs, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. The QVCDC is a 501 (c)3 non-profit organization, certified by the State of Massachusetts and CDFI (U.S.) Treasury.

Do you rent or own your own home?

RentOwn

How many people in your household?

Do you live with relatives?

YesNo

Relationship to you:

If you rent your residence:

	Landlord Name	Landlord Phone	Monthly Rent	Names on Lease	Lease Expiration
If you rent

	Heat	Gas	Electric
Utilities included in rent:

	Yes	No	If no, months owed	$ Past due
Is rent your current?

If you own your own residence:

	Name of owner(s)	Year purchased	Number of units	# of tenants	Rental income
Residence

If you own your own residence:

	Lender	Original loan amount	Current loan balance	Interest rate	Issue date	Maturity date	Monthly payments
First Mortgage

	Yes	No	If no, how many months owed?	How is new rate calculated?	Are real estate taxes current?	Any liens on house?
Does loan reprice?
Is loan current?

If you own your own residence:

	Lender	Line of credit or term loan	Original amount	Current balance	Monthly payment	Interest rate	Issue date	Maturity date
Second Mortgage

Bank Accounts:

	Lending Institution	Account number	Account balance	Checking or Savings	Joint account holders
Bank
Bank
Bank

Loans Credit Cards:

	Lender	Line/loan amount	Current Balance	Interest rate	Monthly payment	Issue date	Maturity date	Maturity date	Collartal	co-borrower
Lender

UPLOAD FILES:

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The undersigned is providing this information to support the extension of credit by Quaboag Valley Business Assistance Corporation. The undersigned understands that Quaboag Valley Business Assistance Corporation is relying on this information for extension of credit, and hereby represents that this information is true, and complete. The undersigned will provide notice of any material adverse change in his/her financial condition including in his/her ability to perform under his/her obligations to Quaboag Valley Business Assistance Corporation. The undersigned authorizes any consumer-reporting agency to give Quaboag Valley Business Assistance Corporation information it may have on the undersigned. The undersigned authorizes Quaboag Valley Business Assistance Corporation to answer questions and/or provide credit information to credit reporting agencies and other parties.

I hereby accept that all claimed above are accurate.*

Date*

Date

Please verify that you are human*