Financial Statement of Debtor (United States)
This is a Small Business Administration (SBA) financial statement. The form provided here is simply a sample of what the actual Form 770 looks like.
SBA LOAN NUMBER __________________________
U.S. SMALL BUSINESS ADMINISTRATION
FINANCIAL STATEMENT OF DEBTOR
(INSERT THE WORD "NONE" WHERE APPLICABLE TO ANY OF THE FOLLOWING ITEMS)
1. NAME __________________________
2. DATE OF BIRTH __________________________ (Month, Day and Year)
3. ADDRESS __________________________
CITY __________________________
STATE __________________________
ZIP CODE __________________________
4. PHONE NO. __________________________
5. SOCIAL SEC. NO. __________________________
6. OCCUPATION __________________________
7. HOW LONG IN PRESENT __________________________
8. EMPLOYER'S NAME __________________________
9. MONTHLY INCOME: __________________________
Salary or wages $__________________________
Commissions $__________________________
Other (state source) $__________________________
Total $__________________________
10. OTHER EMPLOYERS WITHIN LAST 3 YEARS
Name __________________________
Address __________________________
__________________________
Dates of Employment __________________________
Name __________________________
Address __________________________
__________________________
Dates of Employment __________________________
11. NAME OF SPOUSE __________________________
SOCIAL SEC. NO. __________________________
12. DATE OF BIRTH __________________________ (Month, Day and Year)
13. OCCUPATION __________________________
14. HOW LONG IN PRESENT __________________________
15. SPOUSE'S EMPLOYER (Name) __________________________
ADDRESS __________________________
CITY __________________________
STATE __________________________
ZIP CODE __________________________
PHONE NUMBER __________________________
16. MONTHLY INCOME OF SPOUSE: __________________________
Salary or wages $__________________________
Commissions $__________________________
Other (state source) $__________________________
Total $__________________________
17. OTHER EMPLOYERS WITHIN LAST 3 YEARS (Of Spouse)
Name __________________________
Address __________________________
__________________________
Dates of Employment __________________________
Name __________________________
Address __________________________
__________________________
Dates of Employment __________________________
18. OTHER DEPENDENTS: __________________________ NUMBER
Name __________________________
Relationship __________________________
Age __________________________
Name __________________________
Relationship __________________________
Age __________________________
19. TOTAL MONTHLY INCOME OF DEPENDENTS (Except Spouse)
$__________________________
20. FOR WHAT PERIOD DID YOU LAST FILE A FEDERAL INCOME TAX RETURN?
__________________________
21. WHERE WAS TAX RETURN FILED? __________________________
22. AMOUNT OF GROSS INCOME REPORTED $__________________________
23. FIXED MONTHLY EXPENSES: (TO NEAREST DOLLAR)
Rent or House Payment $__________________________
Utilities $__________________________
Food $__________________________
Interest $__________________________
Insurance $__________________________
Debt repayments:
Household furnishings $__________________________
Personal Loans $__________________________
Automobile $__________________________
Doctors and Dentist $__________________________
Other (Specify) $__________________________
TOTAL FIXED MONTHLY EXPENSES $__________________________
24. ASSETS: (Fair Market Value) (SHOW AMOUNTS TO NEAREST DOLLAR)
Cash $__________________________
Checking accounts: (Show location) __________________________ $__________________________
Savings Accounts: (Show location) __________________________ $__________________________
Cash surrender value of life insurance $__________________________
Motor Vehicles:
Make __________________________
Year __________________________
License No. __________________________
$__________________________
Make __________________________
Year __________________________
License No. __________________________
$__________________________
Debts owed to you: (Name of debtor) __________________________ $__________________________
Stocks, bonds and other securities: (Itemize) __________________________
$__________________________
Household furniture and goods $__________________________
Items Used in Trade or Business $__________________________
Other Personal Property; (Itemize) __________________________ $__________________________
Real Estate: (Itemize) __________________________ $__________________________
Other Assets: (Itemize) __________________________ $__________________________
TOTAL ASSETS: $__________________________
LIABILITIES
Bills owed (grocery, doctor, lawyer, etc.) $__________________________
Installment debt (car, furniture, clothing, etc.) $__________________________
Taxes owed:
Income $__________________________
Other: (Itemize) __________________________ $__________________________
Loans payable (to banks, finance companies, etc.) $__________________________
Judgments you owe (Held by whom?) __________________________ $__________________________
Small Business Administration $__________________________
Loans on Life Insurance $__________________________
Mortgages on Real Estate $__________________________
Margin Payable on Securities $__________________________
Other debts: (Itemize) __________________________ $__________________________
Total Liabilities $__________________________
CONTINGENT LIABILITIES $__________________________
25. LOANS PAYABLE:
Owed To __________________________
Date of Loan __________________________
Original Amount $__________________________
Present Balance $__________________________
Terms of Repayments $__________________________
How Secured __________________________
Owed To __________________________
Date of Loan __________________________
Original Amount $__________________________
Present Balance $__________________________
Terms of Repayments $__________________________
How Secured __________________________
26. REAL ESTATE OWNED: (Free & Clear)
Address __________________________
City __________________________
State __________________________
Zip Code __________________________
How Owned (Jointly, individually, etc.) __________________________
Present Market Value $__________________________
27. REAL ESTATE BEING PURCHASED ON
CONTRACT OR MORTGAGE
Address __________________________
City __________________________
State __________________________
Zip Code __________________________
Date acquired __________________________
Balance Owed $__________________________
Name of Seller or Mortgagor __________________________
Purchase Price $__________________________
Date Next Cash Payment Due __________________________
Present Market Value $__________________________
Amount of Next Cash Payment $__________________________
28. LIFE INSURANCE POLICIES:
Company __________________________
Face Amount $__________________________
Cash Surrender Value $__________________________
Outstanding Loans $__________________________
Company __________________________
Face Amount $__________________________
Cash Surrender Value $__________________________
Outstanding Loans $__________________________
29. LIST ALL REAL AND PERSONAL PROPERTY OWNED BY SPOUSE AND DEPENDENTS VALUED IN EXCESS OF $200:
__________________________
__________________________
30. LIST ALL TRANSFERS OF PROPERTY, INCLUDING CASH (BY LOAN, GIFT, SALE, ETC.), THAT YOU HAVE MADE WITHIN THE LAST THREE YEARS. (LIST ONLY TRANSFERS OF $300 OR OVER.)
Property Transferred __________________________
To Whom __________________________
Date __________________________
Amount $__________________________
Property Transferred __________________________
To Whom __________________________
Date __________________________
Amount $__________________________
31. ARE YOU A CO-MAKER, GUARANTOR, OR A PARTY IN ANY LAW SUIT OR CLAIM NOW PENDING?
____ YES ____ NO IF YES, GIVE DETAILS __________________________
32. ARE YOU A TRUSTEE, EXECUTOR, OR ADMINISTRATOR? ____ YES ____ NO
IF YES, GIVE DETAILS __________________________
33. ARE YOU A BENEFICIARY UNDER A PENDING, OR POSSIBLE, INHERITANCE OR TRUST, PENDING OR ESTABLISHED?
____ NO ____ YES IF YES, GIVE DETAILS __________________________
34. WHEN DO YOU FEEL THAT YOU CAN START MAKING PAYMENTS ON YOUR SBA DEBT?
__________________________
35. HOW MUCH DO YOU FEEL THAT YOU CAN PAY SBA ON A MONTHLY OR PERIODIC BASIS?
$__________________________
With knowledge of the penalties for false statements provided by 18 United States Code 1001 ($10,000 fine and/or five years imprisonment) and with knowledge that this financial statement is submitted by me to affect action by the Government, I certify that all the above statement is true and that it is a complete statement of all my income and assets, real and personal, whether held in my name or by another.
Under the provisions of the Privacy Act, loan applicants are not required to give their social security number. The Small Business Administration, however, uses the social security number to distinguish between people with a similar or the same name. Failure to provide this number may not affect any right, benefit or privilege to which an individual is entitled by law but having the number makes it easier for SBA to more accurately identify to whom adverse credit information applies and to keep accurate loan records.
Any Person concerned with the collection of this information, its voluntariness, disclosure or routine under the Privacy Act may contact the Freedom of Information/Privacy Acts Division, Small Business Administration, 409 3rd St., S.W., Washington, D.C. 20416.
SIGNATURE __________________________
DATE __________________________
NOTE: USE ADDITIONAL SHEETS WHERE SPACE ON THIS FORM IS INSUFFICIENT.