Vision Mortgage Company, Ltd.

Personal Financial Statement
Section 9 of 11
Small Business Loan Request
Please print this form. After completion, submit it to your Vision Mortgage Company loan officer.

U.S. Small Business Administration

PERSONAL FINANCIAL STATEMENT

TO BE COMPLETED BY EACH INDIVIDUAL

OMB Approval No. 3245-0188
(copied)
SBA Form 413 (5-91)
 
 
 
As of _____________
Name: Business Phone:
Residence Address: Residence Phone:
City, State and Zip Code:
Business Name of Applicant/Borrower:
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)  
Accounts & Notes Receivable $ ______________ Installment Account (Auto) $ ______________
Life Insurance - Cash Surrender Value Only $ ______________ Monthly Payment $_____  
(Complete in Section 8)   Installment Account (other) $ ______________
Stocks and Bonds $ ______________ Monthly Payment $_____ $ ______________
(Describe in Section 3)   Loan on Life Insurance $ ______________
Real Estate $ ______________ Mortgages on Real Estate $ ______________
(Describe in Section 4)   (Describe in Section 4)  
Automobile - Present Value $ ______________ Unpaid Taxes $ ______________
Automobile - Present Value $ ______________ (Describe in Section 6)  
Other Personal Property $ ______________ Other Liabilities $ ______________
(Describe in Section 5)   (Describe in Section 7)  
Other Assets $ ______________ Total Liabilities $ ______________
(Describe in Section 5)   Net Worth $ ______________
Total Assets $ ______________ Total Liabilities & Net Worth $ ______________
   
Section 1. Source of Income
Source of Income Contingent Liabilities
Salary $ As Endorser or Co-Maker $
Net Investment Income $ Legal Claims and Judgments $
Real Estate Income $ Provision for Federal Income Tax $
Other Income (Describe below) $ 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 Banks 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)
Original Balance
Current Balance
Payment Amount
Frequency (monthly, etc.)
How Secured/ Endorsed
Type of Collateral
           
           
           
           
Section 3. Stocks and Bonds
(Use attachments if necessary. Each attachment must be identified as a 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 attachments if necessary. Each attachment must be identified as a part of this statement and signed.)
  Property A Property B Property C
Type of Property      
Name & Address of Title Holder      
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      
Section 5. Personal Property and Other Assets.
(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 Office, Paper Reduction Project (3245-0188), Office of Management and Budget, Washington, D.C. 20503.
 
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