PFS Information

Assets (Omit Cents)

LIABILITIES (Omit Cents)

Section 1. Source of Income.

Contingent Liabilities

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
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.