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 Date of
Total Value
Quotation/Exchange Quotation/Exchange
Section 4. Real Estate Owned.
(List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part
of this statement and signed.)
Property A Property B Property C
Type of Property
Address
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
(Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms
Section 5. Other Personal Property and Other Assets.
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. PLEASE DO NOT SEND FORMS TO OMB.
