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.