Personal Financial Statement
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4OMB APPROVAL NO.: 3245-0188
EXPIRATION DATE: 01/31/2018
PERSONAL FINANCIAL STATEMENT
8(a) Business Development Program
U.S. SMALL BUSINESS ADMINISTRATION
As of ________________ , ________
individual claiming economic disadvantage must submit personal financial information. When married, an
Each
individual claiming economic disadvantage must submit separate financial information for his or her spouse,
unless the individual and the spouse are legally separated. Additionally, any
proprietor; partner; member of a
limited liability company (LLC); or owner of 10% or more of the equity of the business MUST complete this form and return
to the appropriate SBA Office of Certification and Eligibility at http: or send a hard copy with paper
application to one of the two following locations:
Mail to the following address, if your firm is
Mail to the following address, if your firm is
located in MA, ME, NH, CT, VT, RI, NY, PR (Puerto Rico), VI
located in IL, OH, MI, IN, MN, WI, TX, NM, AR, LA, OK,
(US Virgin Islands), NJ, PA, MD, VA, WV, DC, DE, GA, AL,
MO, IA, NE, KS, CO, WY, ND, MT, UT, SD, CA, HI, GU
NC, SC, MS, FL, KY, TN
(GUAM), NV, AZ, WA, AK, ID, OR
US Small Business Administration
US Small Business Administration
DPCE Central Office Duty Station
Division of Program Certification and Eligibility
Parkview Towers
455 Market Street, 6th Floor
1150 First Avenue
San Francisco, CA 94105
10th Floor, Suite 100I
King of Prussia, PA 19406
See Note: Please complete this form with Personal Information not Business information.
Name
Business Phone
Home Address
Home Phone
City, State, & Zip Code
Business Name of Applicant/Borrower
(Omit Cents)
(Omit Cents)
ASSETS
LIABILITIES
Cash on Hand & in banks…………………………$ ________________
Accounts Payable……………………………$ ______________
Savings Accounts…………………………………..$ ________________
Notes Payable to Banks and Others……….$ ______________
IRA or Other Retirement Account………………...$ ________________
(Describe in Section 2)
(Describe in Section 4)
Installment Account (Auto)…………………..$ ______________
Roth……………… (Describe in Section 4)……..$ ________________
Mo. Payments
$ ___________
Accounts & Notes Receivable…………………….$ ________________
Installment Account (Other)………………....$ ______________
(Describe in Section 5)
Mo. Payments
$ ___________
Life Insurance – Cash Surrender Value Only……$ ________________
Loan(s) Against Life Insurance……………...$ ______________
(Describe in Section 8)
Mortgages on Real Estate…………………...$ ______________
Stocks and Bonds…………………………………..$ ________________
(Describe in Section 4)
(Describe in Section 3)
Unpaid Taxes………………………………….$ _____________
Real Estate…………………………………………..$ ________________
(Describe in Section 6)
(Describe in Section 4)
Other Liabilities………………………………..$ _____________
Automobiles…………………………………………$ ________________
(Describe in Section 7)
(Describe in Section 5, and include
Total Liabilities………………………………....$ _____________
Year/Make/Model)
Net Worth……………………………………….$ _____________
Other Personal Property……………………………$ ________________
i.e. Such as boat, jewelry, etc. (Describe in Section 5)
0
Total
$ _____________
Other Assets………………………………………….$ _______________
*Must equal total in assets column.
(Describe in Section 5)
Mutual Funds (Describe in Section 3)
Applicant’s Business Equity……………………….$_________________
Equity in other firms…………………………………$________________
0
Total
$ ________________
Section 1.
Source of Income.
Contingent Liabilities
Salary………………………………………………….$ ________________
As Endorser or Co-Maker…………………….$ _____________
Net Investment Income……………………………...$ ________________
Legal Claims & Judgments…………………..$ _____________
Real Estate Income………………………………….$ ________________
Provision for Federal Income Tax…………....$_____________
Other Income (Describe below)*…………………...$ ________________
Other Special Debt…………………………….$ _____________
*Alimony or child support payments should not be disclosed in “Other Income” unless it is desired to have such payments counted toward total income.
SBA Form 413 (8a) (09-14) Previous Editions Obsolete
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