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Personal Financial Statement (United States)

This is a Small Business Administration (SBA) statement of personal finances. The form provided here is simply a sample of what the actual Form 413 looks like.

U.S. SMALL BUSINESS ADMINISTRATION
PERSONAL FINANCIAL STATEMENT

As of _______________________, 20_______

Complete this form for: (1) each proprietor, or (2) each limited partner who owns 20% or more interest and each general partner, or (3) each stockholder owning 20% or more of voting stock, or (4) any person or entity providing a guaranty on the loan.

Name ______________________________

Residence Address ______________________________

City ______________________________

State, ______________________________

Zip Code ______________________________

Business Name of Applicant/Borrower __________________________

Business Phone ______________________________

Residence Phone ______________________________

ASSETS (Omit Cents)

Cash on hands & in Banks $______________________________

Savings Accounts $______________________________

IRA or Other Retirement Account $______________________________

Accounts & Notes Receivable $______________________________

Life Insurance-Cash Surrender Value Only

$______________________________
(Complete Section 8)

Stocks and Bonds $______________________________
(Describe in Section 3)

Real Estate $______________________________

Automobile-Present Value $______________________________
(Describe in Section 4)

Other Personal Property $______________________________
(Describe in Section 5)

Other Assets $______________________________
(Describe in Section 5)

Total $______________________________

LIABILITIES (Omit Cents)

Accounts Payable $______________________________

Notes Payable to Banks and Others

$______________________________
(Describe in Section 2)

Installment Account (Auto) $______________________________

Mo. Payments $______________________________

Installment Account (Other) $______________________________

Mo. Payments $______________________________

Loan on Life Insurance $______________________________

Mortgages on Real Estate $______________________________
(Describe in Section 4)

Unpaid Taxes $______________________________
(Describe in Section 6)

Other Liabilities $______________________________
(Describe in Section 7)

Total Liabilities $______________________________

Net Worth $______________________________

Total $______________________________

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.

______________________________

______________________________

*Alimony or child support payments need not be disclosed in "Other Income" unless it is desired to have such payments counted toward total income.

Section 2. Notes Payable to Bank and Others.

(Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)

Name and Address of Noteholder(s)

Name ______________________________

Address ______________________________

City ______________________________

State, ______________________________

Zip Code ______________________________

Original Balance $______________________________

Current Balance $______________________________

Payment Amount $______________________________

Frequency (monthly, etc.) ______________________________

How Secured or Endorsed Type of Collateral

______________________________

Name ______________________________

Address ______________________________

City ______________________________

State, ______________________________

Zip Code ______________________________

Original Balance $______________________________

Current Balance $______________________________

Payment Amount $______________________________

Frequency (monthly, etc.) ______________________________

How Secured or Endorsed Type of Collateral

______________________________

Name ______________________________

Address ______________________________

City ______________________________

State, ______________________________

Zip Code ______________________________

Original Balance $______________________________

Current Balance $______________________________

Payment Amount $______________________________

Frequency (monthly, etc.) ______________________________

How Secured or Endorsed Type of Collateral

______________________________

Section 3.

Number of Shares ______________________________

Name of Securities ______________________________

Cost $______________________________

Market Value Quotation/Exchange

$______________________________

Date of Quotation/Exchange ______________________________

Total Value $______________________________

Number of Shares ______________________________

Name of Securities ______________________________

Cost $______________________________

Market Value Quotation/Exchange

$______________________________

Date of Quotation/Exchange ______________________________

Total Value $______________________________

Section 4.

(List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part of this statement and signed.)

Property A

Type of Property ______________________________

Address ______________________________

City ______________________________

State, ______________________________

Zip Code ______________________________

Date Purchased ______________________________

Original Cost $______________________________

Present Market Value $______________________________

Name & Address of Mortgage Holder

Name ______________________________

Address ______________________________

City ______________________________

State, ______________________________

Zip Code ______________________________

Mortgage Account Number ______________________________

Mortgage Balance $______________________________

Amount of Payment per Month/Year $__________________________

Status of Mortgage ______________________________

Property B

Type of Property ______________________________

Address ______________________________

City ______________________________

State, ______________________________

Zip Code ______________________________

Date Purchased ______________________________

Original Cost $______________________________

Present Market Value $______________________________

Name & Address of Mortgage Holder

Name ______________________________

Address ______________________________

City ______________________________

State, ______________________________

Zip Code ______________________________

Mortgage Account Number ______________________________

Mortgage Balance $______________________________

Amount of Payment per Month/Year $__________________________

Status of Mortgage ______________________________

Section 5. (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 SBA/Lender to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify the above and the statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of either obtaining a loan or guaranteeing a loan. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by the U.S. Attorney General (Reference 18 U.S.C. 1001).

Signature: ______________________________

Date: ______________________________

Social Security Number: ______________________________

Signature: ______________________________

Date: ______________________________

Social Security Number: ______________________________

PLEASE NOTE: The estimated average burden hours for the completion of this form is 1.5 hours per response. If you have questions or comments concerning this estimate or any other aspect of this information, please contact Chief, Administrative Branch, U.S. Small Business Administration, Washington, D.C. 20416, and Clearance Officer, Paper Reduction Project (3245-0188), Office of Management and Budget, Washington, D.C. 20503.


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