Personal Financial Statement

							                                    Personal Financial Statement
               (A separate statement is to be submitted for each principal of the business.)

Your Personal Data
Name:                                                Date of Birth:                          SIN:
Address:                                             City:                                   Province:
Postal Code:                   Own      Rent      Other  How long:            years       Phone: ( )
Occupation:                                          Employer:                               How long:        years
Employer’s Phone: ( )                                Marital Status:                         # of dependents:
Principal Financial Institution:                     Contact:                                Phone: ( )


Personal Data on Your Spouse (under the Laws of Canada or the Provinces, your spouse may have a legal interest in
or obligations arising from your business dealing and may also have an interest in your personal assets)
Spouse’s Name:                                      Occupation:                          Monthly Salary:
Employer:                                           How long:                            Phone: ( )

Personal Equity Statement
Financial Information as of month:           day:    year:
                         Assets                                                          Liabilities
Total Chequing                                $              Bank Loans                                          $
Total Savings
Life Insurance (Cash Value)                                  Mortgages on Real Estate
Automobile Make              Year                            (Schedule B)
Marketable Securities (Schedule A)
Accounts/Notes Receivable                                    Credit Cards
                                                             (please itemize)

Real Estate (Schedule B)
Retirement Accounts
Other Assets                                                 Other Obligations
(including equity investment in business)                    (please itemize)

Total Assets                           (A)    $              Total Liabilities                             (B)   $
                                                             Net Worth                                 (A – B)   $


Statement of Income and Expenditures
Monthly  or Yearly 
Income                                                       Expenditures
Salaries, Wages & Commission         $                       Mortgage or Rent                                    $
Rental Income                                                Property Taxes & Assessments
Business or Professional Income                              Credit Card Payments
Other (please itemize)                                       Loan Payments
                                                             Insurance
                                                             Estimated Living Expenses
                                                             Income Tax
                                                             Other

                            Total Income      $                                          Total Expenditures      $
Schedule A - Marketable Securities (Stocks, Bonds etc.)
  Quantity                      Description                                Market            Where          Pledged as
                                                                           Value             Quoted         Collateral?
                                                                                                          YES          NO
                                                                      $




                 Total                                                $


Schedule B – Real Estate Owned
                                                                                             Monthly
Please Provide Details on            Tax             Amount of     Mortgage              Taxes,    Maintenance          Rental
your own share of real estate    Assessment          Mortgage      Payments            Insurance                       Income
                                    Value              Liens                                                         (If rented)
Property Address
                                $                $               $                 $               $             $
                                $                $               $                 $               $             $
                                Mortgagor                        Amount                            Maturity Date
                                 st
  Mortgage Information          1 :
                                 nd
                                2 :
Percentage Ownership            Year Acquired:                   Purchase Price:                   Current Appraised Value:
%


General Information (please circle)
Have you ever had an asset repossessed? Yes  No             Have you ever been declared a Bankrupt?          Yes  No 
                                                              Year:
Are you party to any claims or lawsuits?   Yes  No          Do you owe any taxes prior to the current year? Yes  No 
Are you providing your personal support for obligations not listed above ( i.e. cosigner, endorser, guarantor)?Yes  No 
If you answered yes to any of the foregoing questions, please provide details:




The undersigned declare(s) that the statements made herein are for the purpose of obtaining business financing and are
to the best of my/our knowledge true and correct. The applicant(s) consent(s) to the Muskoka Community Futures
Development Corporation making any enquires it deems necessary to reach a decision on this application, and consent(s)
to the disclosure at any time of any credit reporting agency or to any one with whom I/we have financial relations.


Dated                                                              Dated


Witness                                                            Signature(s)


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