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Directions for Personal Financial Statement
1. DO NOT LEAVE ANY LINES BLANK. Enter N/A if not applicable. Submit all the required
support as listed in the following steps. Otherwise, the application package will be returned
to you as incomplete and your establishment as a DBE/SMWBE will be delayed until the
requested information is received and reviewed. The Personal Financial Statement
should be signed and notarized.
2. For cash in banks and savings accounts, provide a copy of bank or credit union statements.
The closing date of the bank statement should be as close as possible to the date of the
personal financial statement.
3. For IRA or other retirement accounts, provide a copy of the IRA or other retirement account
statement(s).
4. The current market value of stocks and bonds held should be completely described in
Section 2. The quoted information is subject to verification. A recent statement of the
brokerage firms(s) reflecting the value(s) must be submitted.
5. The personal residence is to be excluded from the total carried forward to page 1, but
include this information on the real estate property listing on page 2. Should the information
provided not appear reasonable, you will be asked to provide property appraisals. Farm
property may be listed here or in the other assets as a non-DBE/SMWBE status business
enterprise. If farm property is listed in the real estate section, farm equipment should be
listed at current market value in the other assets section.
6. The automobile present value should be retail Blue Book value. Please note any
adjustments to the value.
7. Personal property will be household furnishings, jewelry, guns, cameras, electronic
equipment, etc. This category could also include motorcycles, motor home(s), boat(s) and
other recreational vehicles. Copies of insurance policies on these items must be submitted.
8. Other assets could be other enterprises in which the applicant is a partial owner or has
ownership as a marital asset. For other business assets, a copy of the most recent
balance sheet must be submitted along with information as to the applicant ownership share
of the net worth.
9. A copy of the most recent loan balance must be submitted for any notes payable, and
automobile installment accounts, credit card liabilities or mortgages on real estate.
10. Other liabilities could be liabilities related to other assets, such as farm equipment.
This is a legally binding document. Any falsification is grounds for immediate removal or
denial from Small, Minority, Woman Owned or Disadvantaged business status. All this
information is held in very strict confidence and is under lock and key AT ALL TIMES.
1
2/24/2006 Revised
METROPOLITAN NASHVILLE AIRPORT AUTHORITY
PERSONAL FINANCIAL STATEMENT
As of ______________, _________
Name Business Phone
Residence Address Residence Phone
City, State, & Zip Code
Business Name of applicant
ASSETS (Omiit Cents) LIABILITIES (Omit Cents)
Cash on hand in Banks $___________________ Accounts payable $_____________________
Savings Accounts $___________________ Notes Payable to Banks and Others $_____________________
(Describe in Section 2)
IRA or Other Retirement Account Installment Account (Auto) $_____________________
$___________________ Mo. Payments $___________
Accounts & Notes Receivable $___________________ Installment Account (Other) $_____________________
Mo. Payments $___________
Life insurance-Cash Surrender
Value Only $___________________ Loan on Life Insurance $_____________________
(Complete Section 8)
Stocks and Bonds Mortgages on Real Estate
(Describe in Section 3) $___________________ (Describe in Section 4) $_____________________
Real Estate Unpaid Taxes
(Describe in Section 4) $___________________ (Describe in Section 6) $_____________________
Other Liabilities
Automobile – Present Value $___________________ (Describe in Section 7) $_____________________
Personal Property
(Describe in Section 5) $___________________ TOTAL LIABILITIES $_____________________
Other Assets
(Describe in Section 5) $___________________
TOTAL ASSETS $___________________ TOTAL ASSETS – TOTAL LIABILITIES =
NET WORTH $______________________
Section 1. Source of Income Contingent Liabilities
Salary $_____________________ As Endorser or Co-Maker $______________________
Net Investment Income $_____________________ Legal Claims & Judgments $______________________
Real Estate Income $_____________________ Provision for Federal Income Tax $______________________
Other Income $_____________________ Other Special Debt $______________________
(Describe in Section 1 below)
Description of Other Income in Section 1
*Alimony or child support payments need not be disclosed in “Other Income” unless it is desired to have such payments counted toward total income.
Section 2. Notes Payable to Banks and Other. (Use attachments if necessary. Each attachment must be identified as part of this statement and signed.)
Names and Address of Note holder(s) Original Current Payment Frequency How Secured or Endorsed Type
Balance Balance Amount (monthly, etc.) of Collateral
2/24/2006 Revised
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
Quotation/Exchange Quotation/Exchange Total Value
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.)
Primary Residence Property 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
Section 5. Personal Property and Other Assets.. (Describe, and if any is pledged as security, state name and address of lien holder, amount off
lien, terms 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 certify to MNAA that the above statements contained in the attachments are true and accurate as the stated dates(s). 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
Notary
Subscribed and sworn to before me this ________ day of ____________ 20____
Signed _________________________, Notary Public in and for the
County of _____________________________, State ________________
My Commission Expires ___________________________
2/24/2006 Revised 2
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