Fillable Personal Financial Statement (City of Cincinnati)

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Personal Financial Statement (City of Cincinnati)

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U.S.A. forms for City of Cincinnati

BROWSE CITY OF CINCINNATI (OH) FORMS

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Personal Financial Statement
Values as of (Date):
Name:
Spouse Name:
Home Bus. Phone:
Address:
Bus. Email:
Stocks & Bonds (See Section 3 Below)
NET WORTH (ASSETS LESS LIABILITIES)
Total Value of Asset
Your % of
Ownership
Attach additional sheets if necessary.
Relationship to
You Date of Transfer
Amount Paid by
Transferee
Value at Time
of Transfer
TOTAL
Assets Held in Trust for Which You Are the Primary Beneficiary
Attach additional sheets if necessary.
Date Trust
Established
Value of Assets
Held in Trust
Can Principle Be
Distributed to
You? (Y/N)
Is Trust
Revocable?
(Y/N)
Name of the Trust Name(s) of Trust Grantor(s) Current Trustee's Name
For assets held jointly with
spouse or another person,
include only the value of
your interest.*
ASSETS
LIAB
ILITIES
AND NET
WORTH
You and your spouse each should
report 1/2 of the liabilities for which
you are jointly liable,
*For any assets held jointly with someone other than your spouse, provide the following information (use additional sheet if
necessary):
Description of Asset
TOTAL ASSETS
Transfers To Immediate Family Members within the Past Two Years
Description of Property/Asset
Transferred
Name of Person to Whom
Transfer Was Made
Joint w
Spouse? Y/N
Dollar
Value
Personal Notes Payable (See Section 2 Below) (Home
Equity Loan, Car Loan, etc. Do not include business
loans)
Unpaid Personal Income Taxes (Local, State, Fed)
Reason for Transfer
Joint w
Spouse? Y/N
Cash on Hand, Checking and Savings Accounts
Real Estate Owned (See Section 4 Below) (Do
Not Include Value of Primary Personal Residence)
Personal Vehicles (Cars, Trucks, etc) (See Section
9 Below)
Other Owned Vehicles (RVs, Boats, etc)
Other Personal Property (Jewelry, artwork, etc.)
TOTAL LIABILITIES
Dollar
Value
Retirement Accounts (See Section 8 Below)
Equity in Any Other Businesses (See Section 5
Below) (exclude the business applying)
Real Estate Mortgages Payable (See Section 4 Below) (Do
Not Include Mortgages on Primary Personal Residence)
Cash Value of Life Insurance (See Section 7
Below)
Life Insurance Loans (See Section 7 Below)
Other Liabilities - Not otherwise listed
Personal Notes Receivable (See Section 6 Below)
Revolving Credit Account Balances
Auto Loan Balances (See Section 9 Below)
IF YOU ARE MARRIED, YOUR SPOUSE MUST COMPLETE AND SUBMIT A SEPARATE PERSONAL FINANCIAL STATEMENT.
Revised 4.7.2017
Contingent Liabilities
Attach additional sheets if necessary.
Total Amount of
Potential Liabilty
Date Liability
Will Expire or
Terminate
TOTAL
Section 1. Sources of Income
TOTAL
Section 3. Stocks & Bonds
Attach additional sheets if necessary.
TOTAL
Section 4. Real Estate Owned (and related debt, if applicable)
Attach additional sheets if necessary.
TOTAL
Section 2. Notes Payable: Banks & Other Institutions (Not Including Real Estate Mortgages)
TOTAL
Secured by What Assets
(Collateral)?
Monthly Payment
Outstanding
Balance
Identify all existing loans that are not secured by real estate. Attach additional sheets if necessary.
Term of the Loan
Type of Income
Salary:
Property Address(es):
Name of Business:
Source:
Amount
Pledged
Basis for Valuation
Address of Property
Type of Property
(Commercial, Rental,
Vacation Home,
Farm etc)
Pledged for
Financing? Yes/No
Market Value
Type?
Stock/
Bond
Present Value
Mortgage Balance
Name(s) of Person(s) with Primary
Responsibility
Annual Amount
Mortgage Holder Titled in the Name(s) of
Basis of
Valuation
Agency or Name of Company Issuing
Security or Bond Asset Held In Name(s) Of
Number of
Shares or Face
Value of Bonds
Conditions That Will Trigger
Obligation to Pay
Type of Contingent Liability
(Guarantor, Co-Signer, Legal
Action, etc.)
To What Creditor May Payment Have
to be Made?
Name of Institution
Original
Balance Name(s) on Account
Rental Income: (Complete Section 4)
Other Business Income: (Complete Section 5)
Other Income: (Complete Sections 6 and 8)
Source
Employer:
Revised 4.7.2017
Section 5. Equity in LLCs, S-Corps, or Other Businesses (exclude business for which you are applying)
Attach additional sheets if necessary.
Ownership
Percentage
Valuation
TOTAL
Section 6. Personal Notes Receivable and Personal Loans to Others
Attach additional sheets if necessary.
TOTAL
Section 7. Cash Value Life Insurance Policies
Attach Additional sheets if necessary.
Cash Surrender
Value
Loan Balance
(if any) Monthly Payment
Section 8. Retirement Accounts
Attach Additional sheets if necessary.
TOTAL
Section 9. Vehicles
Attach Additional sheets if necessary.
Year Mileage Condition Value
Loan Balance
(if any)
TOTAL
Type of BusinessBusiness Name
I authorize the City of Cincinnati and the Department of Economic Inclusion to make inquiries, as necessary, to verify the accuracy of the
statements made and to determine my creditworthiness. I certify that the information contained on each of the 3 pages of this Personal
Financial Statement and the statements contained in any attachments submitted herewith are true and accurate as of the noted following
"Values as of" on the first page. These statements are made for the purpose of obtaining Small Business Enterprise Certification under the
Cincinnati Municipal Code. I understand that, pursuant to Cincinnati Municipal Code 323-7, FALSE statements will result in the revocation of the
certification that was granted on the basis of those fraudulent statements. I further understand that FALSE statements may result in possible
prosecution.
TOTAL
Date Signed
Amount
Pledged
Applicant's
Signature
Pledged for
Financing? Yes/No
Current Balance Name on the Account
Balance
Outstanding
Names of Other Shareholders,
Patrners or Members
Basis for Valuation
(Appraisal, Buy-Sell Agreement,etc)
Collateral
(if any)
Maturity Date Loan Purpose Original Loan Balance
Name of Company
Name(s) of Debtor(s)
Face Amount Beneficiaries
Loan Origination
Date
Make
Model
Titled in the Name(s) Of
Name of Plan Trustee or Financial Institution Holding Account
Account Type
(401k, IRA, Roth,
etc)
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Personal Financial Statement (City of Cincinnati)

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Completed 9 February 2021

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