VIEWS: 31 PAGES: 2 POSTED ON: 5/17/2012
PERSONAL STATEMENT OF FINANCIAL AFFAIRS All shareholders and/or partners must complete and attach to Application form. Surname: First Name & Initial: Social Insurance # Birth Date: Home Address: City/Town: Postal Code: Rent/Own Home or Other: Occupancy (Years): Home Telephone: Fax Number: Marital Status: Spouse’s Surname: Spouse’s First Name: Number of Dependants: Your Employer: Position: How long? Your Annual Income: Business Telephone: Spouse’s Annual Income: Total Gross Family Income: Primary Bank: PERSONAL NET WORTH STATEMENT LIST ALL ASSETS LIST ALL LIABILITIES & DEBT Cash & Savings: $ Mortgage - First: $ Term Deposits/G.I.C.: $ Mortgage - Second: $ Stocks/Bonds/Mutual Funds: $ Bank Lines of Credit: $ R.R.S.P. /Company Pension: $ Overdraft Facility: $ Real Estate - Residence: $ Bank Personal Loans: $ Real Estate - Other: $ Credit Cards: $ Automobiles: $ Private Loans: $ Recreational Vehicles: $ Amt of loan cosigned $ for or guaranteed: Other - Describe: $ Other - Describe: $ $ $ TOTAL ASSETS: $ TOTAL LIABILITY: $ PERSONAL NET WORTH (Assets - Liabilities): = $ Detailed Description of Assets Describe your Real Estate: Property Address Reg. Owner Value Mtge Balance Lender Describe your Automobiles and Recreational Vehicles: Year & Make Model Value Loan Amount Balance Lender Describe your Cash, Savings, Term Deposits, G.I.C.s, R.R.S.P.s and Company Pensions: Asset Description Financial Institution Telephone Balance Maturity Describe your Stocks, Bonds, Mutual Funds, and Life Insurance: Asset Description Agent/Brokerage Telephone Cash Value # of Units Maturity Detailed Description of Liabilities and Debt Describe your Loans, Credit Lines, Credit Cards, and loans you have co-signed or guaranteed for others (excluding mortgages and vehicle loans which have been described under Assets on page 1 & 2): Debt Description Lender/Creditor Telephone Credit Limit Balance Security GENERAL INFORMATION 1. Have you ever had an asset repossessed by a creditor? If yes, explain 2. Are you involved in any lawsuits or claims that could effect your financial situation? If so, explain 3. Have you ever-declared bankruptcy? YES ( ) NO ( ) If yes, when?__________________________ Are you discharged? YES ( ) NO ( ) If not, why? 4. Do you have any outstanding liability to the Receiver General, Workers Compensation or Canada Revenue Agency? 5. Are you a shareholder, director or stakeholder of any other business, corporation, partnership, proprietorship, etc.? If so, describe the nature of your involvement and/ or interest. APPLICATION DECLARATION The undersigned hereby declares that all information provided herein is true, complete and correct, to the best of my knowledge. I understand that the information contained herein will be used by the Business Development & Investment Corporation(“BDIC”) to determine BDPF eligibility. I further consent to the BDIC making any credit and general inquiries necessary in relation to this application and to the disclosure of any credit information about me, to any credit reporting agency, organization or person with whom I have a financial relationship. This is to include the GNWT Department of Finance. DATE: SIGNATURE: X
"Personal Statement of Financial Affairs"