PFS - RL

Name
Business Phone (XXX-XXX-XXXX)
Format: (000) 000-0000.
Home Address
Home Phone(xxx-xxx-xxxx)
Format: (000) 000-0000.
City State Zip Code
Business Name of ApplicantBorrower
Business Address if different than home address
Business Type:
This information is current as of (month/day/year)
Witin 90 days of submission for 7(a)/504/SBG/ODA/WOSB or within 30 days of submission for 8(a) BD
WOSB applicant only, Married
ASSETS
Cash on Hand & in banks
Savings Accounts
IRA or Other Retirement Account
Accounts & Notes Receivable
Description in Section 5
Life Insurance Cash Surrender Value Only
Description in Section 8
Stocks and Bonds
Description in Section 3
Real Estate
Automobiles
Description in section 5, include Year/Make/Model
Other Personal Property
Describe in section 5
Other Assets
Describe in section 5
Total Assets
Add all above Assets
LIABILITIES
Accounts Payable
Notes Payable to Banks and Others
Describe in Section 2
Installment Account Auto
Loan Balance
Monthly Auto Payments
Installment Account (Other)
Monthly Installment Payments (Other)
Loans Against Life Insurance
Mortgages on Real Estate
Describe in Section 4
Unpaid Taxes
Describe in Section 6
Other Liabilites
Describe in Section 7
Total Liabilities
Add all above liabilites
Net Worth
Total Assets minus Total Liabilities
Total
Must equal to Total Assets
SOURCE OF INCOME
Salary
Net Investment Income
Real Estate Income
Other Income
Describe in Section 1
CONTINGENT LIABILITES
As Endorser or CoMaker
Legal Claims & Judgments
Provision for Federal Income Tax
Other Special Debt
SECTION 1
Description of Other Income in Section 1
(Alimony or child support payments should 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 (Please send the remaining details via email if there are more mortgages than listed below. reena@rlare.com)

Rows	Name and address of Noteholder(s)	Original Balance	Current Balance	Payment Amount	Frequency (Monthly etc.)	How secure of endorsed type of collateral
1
2
3
4
5

SECTION 3

Stocks and Bonds (Please send the remaining details via email if there are more stocks than listed below. reena@rlare.com)

Rows	Number of Shares	Name of securities	Cost	Market Value Quotation/Exchange	Date of Quotation /Exchange	Total Value
1
2
3
4

SECTION 4

Real Estate Owned (Please send the remaining details via email if there are more properties than listed below. reena@rlare.com)

Rows	Property A	Property B	Property C
Type of Real Estate (e.g. Primary Residence, Other Residence, Rental Property, Land etc
Address
Date Purchased
Original Cost
Present Market Value
Name of Mortgage Holder
Mortgage Balance
Amount of Payment Per Month
Status of Mortgage (Current/Late)

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 terms of payment and if delinquent describe delinquency
SECTION 6
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 the SBA/Lender/Surety Company to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness.

CERTIFICATION: (to be completed by each person submitting the information requested on this form and the spouse of any 20% or more owner when spousal assets are included)

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. | understand that SBA or its participating Lenders or Certified Development Companies or Surety Companies will rely on this information when making decisions regarding an application for a loan, surety bond, or participation in the WOSB or 8(a) BD program. I further certify that I have read the attached statements required by law and executive order.-
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Print Name
Social Security No
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Print Name
Social Security No
Should be Empty:

ASSETS

LIABILITIES

SOURCE OF INCOME

CONTINGENT LIABILITES

SECTION 1

SECTION 2

SECTION 3

SECTION 4

SECTION 5

SECTION 6

SECTION 7

SECTION 8