[sdrs_pfs_application_view] Please enable JavaScript in your browser to complete this form. - Step 1 of 6Name *Business Phone *Home Phone *Email *AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBusiness Name of Applicant *NextAssets (Omit Cents)Cash on Hand & in banks *IRA or Other Retirement Account *Life Insurance – Cash Surrender Value OnlyReal EstateOther Personal PropertySavings Accounts *Accounts & Notes ReceivableStocks and BondsAutomobilesOther AssetsTotalLiabilities(Omit Cents)Accounts Payable *Installment Account (Auto)Installment Account (Other)Loan(s) Against Life InsuranceUnpaid TaxesTotal LiabilitiesNotes Payable to Banks and Others *Mo. PaymentsMo. Payments (Other)Mortgages on Real EstateOther LiabilitiesNet WorthTotal(*Must equal total in assets column. )PreviousNextSection 1. Source of IncomeSalaryReal Estate IncomeNet Investment IncomeOther Income (Describe below)Contingent LiabilitiesAs Endorser or Co-MakerProvision for Federal Income TaxLegal Claims & JudgmentsOther Special DebtDescription of Other Income in Section 1.PreviousNextSection 2. Notes Payable to Banks and Others. (Use attachments if necessary. Each attachment must be identified as part of this statement and signed.)Names and Addresses of Noteholder(s)Original BalanceCurrent BalanceOriginal Balance (copy)Current Balance (copy)Names and Addresses of Noteholder(s) (copy) (copy)Original Balance (copy) (copy)Current Balance (copy)Names and Addresses of Noteholder(s) (copy) (copy) (copy)Original Balance (copy) (copy) (copy)Current Balance (copy) (copy)Names and Addresses of Noteholder(s) (copy) (copy) (copy) (copy)Original Balance (copy) (copy) (copy) (copy)Current Balance (copy) (copy) (copy)Payment AmountFrequency (monthly, etc.)How Secured or Endorsed Type of CollateralOriginal Balance (copy)Current Balance (copy)Names and Addresses of Noteholder(s) (copy) (copy)Original Balance (copy) (copy)Current Balance (copy)Names and Addresses of Noteholder(s) (copy) (copy) (copy)Original Balance (copy) (copy) (copy)Current Balance (copy) (copy)Names and Addresses of Noteholder(s) (copy) (copy) (copy) (copy)Original Balance (copy) (copy) (copy) (copy)Current Balance (copy) (copy) (copy)Section 3. Stocks and Bonds. (Use attachments if necessary. Each attachment must be identified as part of this statement and signed.)Number of SharesName of SecuritiesCostOriginal Balance (copy)Current Balance (copy)Names and Addresses of Noteholder(s) (copy) (copy)Original Balance (copy) (copy)Current Balance (copy)Names and Addresses of Noteholder(s) (copy) (copy) (copy)Original Balance (copy) (copy) (copy)Current Balance (copy) (copy)Market Value Quotation/ExchangeDate of Quotation/ExchangeTotal ValueOriginal Balance (copy)Current Balance (copy)Names and Addresses of Noteholder(s) (copy) (copy)Original Balance (copy) (copy)Current Balance (copy)Names and Addresses of Noteholder(s) (copy) (copy) (copy)Original Balance (copy) (copy) (copy)Current Balance (copy) (copy)Section 4. 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 AProperty BProperty CType of Real Estate (e.g.Primary Residence, Other Residence, Rental Property,Land, etc.)AddressDate PurchasedOriginal CostPresent Market ValueName & Address of Mortgage HolderMortgage Account NumberMortgage BalanceAmount of Payment per Month/YearStatus of MortgagePreviousNextSection 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. 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. I 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 or a surety bond. I further certify that I have read the attached statements required by law and executive orderSignaturePrint NameSignaturePrint NameDateSocial Security No.DateSocial Security No.Document UploadPreviousNextSubmit
