PNWMarch09 by tarrancebellamy

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									                           City of Charlotte Small Business Opportunity Program
                                              Personal Net Worth Statement

Applicant Name:
Residence Address:
City, State, Zip Code:
Business Name:
Home Phone:                                                  Email:

                        ASSETS                                                       LIABILITIES
Real Estate                                                  Mortgages
1.Residential Home                             $             1.Residential Home                             $
  Estimated Market Value                                        Principal Balance
2. Other Real Estate                           $             2. Other Real Estate                           $
   Estimated Market Value                                       Principal Balances
Personal Property                                            Loans And Other Debts
3. Automobiles                                 $             3. Automobile Loans                            $
   Blue Book Value Of All Cars
4. Other Vehicles                              $             4. Accounts Payable                            $
   (Motor Homes, Boats, Motorcycles, etc.)
5. Jewelry                                     $             5. Installment Accounts                        $
  Estimated Value                                                (Accounts with a set regular payment)
6. Household Items                             $             6. Unpaid Taxes                                $
  (Furniture, Computers, Electronics, etc.)
7. Other Assets                                $             7. Other Liabilities                           $
Investments
8. Retirement Accounts                         $
   (401K, IRAs, Keogh, etc.)
9. Stocks, Bonds and Mutual Funds              $
   (Estimated Current Value)
10. Ownership in Applicant Business            $
   (Estimated Current Value)
11. Ownership in Other Businesses              $
   (Estimated Current Value)
Cash
12. Cash on Hand                               $
   Checking and Saving Accounts
13. Other                                      $

                                                                                             PROGRAM EXCLUSIONS
                                                             8. Ownership in Applicant Business       $
                                                             9. Retirement Accounts                   $
                                                             10. Eligible Equity in Residential Home  $
Total Assets (Add lines 1-13)                  $             Total Liabilities (Add lines 1-10)       $
                                                             TOTAL NET WORTH                          $
                                                                 (Total Assets minus Total Liabilities)



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                                                                                            Personal Net Worth- Rev.3/2009
SCHEDULE A- Real Estate Owned
                                      PROPERTY A                     PROPERTY B                      PROPERTY C
Type of Property
Address
Date Purchased
Original Cost
Present Market Value
Mortgage Holder
Mortgage Balance
Monthly Payment

SCHEDULE B- Other Personal Property and Other Assets (Describe, and if any is pledged as security, state name
and address of lien holder, amount of lien and terms of payment).




Every person who signs this financial statement certifies and agrees that (1) the information provided is true and
complete and gives an accurate description of such person financial condition; except as listed on this statement, (2)
title to all listed assets is solely in the name of such person and no other person or entity has interest in such assets,
unless otherwise listed in this statement. In the event of any change in such person's financial condition, such person
agrees to send written notice to the City of Charlotte- SBOP within 30 business days of the occurrence of any change.
Please note that additional supporting documentation can be required.

I certify under penalty of perjury than my personal net worth does not exceed $750,000 and that my business
headquarters resides in _____________________ County.
The City of Charlotte is authorized to verify the accuracy of this statement to determine whether I meet the size
standards of its Small Business Opportunity Program.

Print Name _______________________________ Signature _____________________ Today's Date_____________

Print Name _______________________________ Signature _____________________ Today's Date_____________

NOTARY CERTIFICATE
                                                                                                     NOTARY SEAL
State of _________________________________
County of ________________________________
Subscribed and sworn to before me this ________ day of _______________________, 20_____.

Signature of Notary Public ________________________________
Print Name of Notary Public _______________________________

County of Residence ____________________ Date Commission Expires __________________.

                                                                                              This page must be notarized




                                                           -2-
                                                                                             Personal Net Worth- Rev.3/2009

								
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