"Directions for Personal Financial Statement"
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