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Personal Statement of Financial Affairs

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					                           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

				
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posted:5/17/2012
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