PFS Information Name: Business Phone: Home Phone: Email Home Address: City State Select StateAlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyomingUS Virgin Islands Zip Business Name of Applicant Assets (Omit Cents) Cash on Hand & in banks * Savings Accounts * IRA or Other Retirement Account… * Accounts & Notes Receivable… Life Insurance – Cash Surrender Value Only Stocks and Bonds Real Estate Automobiles… Other Personal Property… Other Assets Total LIABILITIES (Omit Cents) Accounts Payable* Notes Payable to Banks and Others* Installment Account (Auto) Mo. Payments Installment Account (Other) Mo. Payments (Other) Loan(s) Against Life Insurance Mortgages on Real Estate Unpaid Taxes Other Liabilities Total Liabilities Net Worth… Total(*Must equal total in assets column. ) Section 1. Source of Income. Salary… Net Investment Income Real Estate Income Other Income (Describe below)* Contingent Liabilities As Endorser or Co-Maker… Legal Claims & Judgments Provision for Federal Income Tax Other Special Debt Description of Other Income in Section 1.: Section 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 Balance Current Balance Payment Amount Frequency (monthly, etc.) How Secured or Endorsed Type of Collateral Section 3. Stocks and Bonds. (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 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 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 & Address of Mortgage Holder Mortgage Account Number Mortgage Balance Amount of Payment per Month/Year Status of Mortgage 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. 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 order Signature Date Print Name Social Security No. Signature Date Print Name Social Security No. Document Upload :
