Blank Personal Financial Statement Template for Canada Norfolk District

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Blank Personal Financial Statement Template for Canada Norfolk District Powered By Docstoc
					                                                                    Norfolk District Business Development Corporation
                                                                                        Box 732, 4077 Highway #3 East
                                                                                                Simcoe, ON N3Y 4T2
                                                                           Tel: (519) 428-2323 Fax: (519) 428-0074

                   SEB APPLICATION FORM

   Proposed Business Name:

                    Date Prepared:

  Business Concept: __________________________________________________


                    Blank electronic template available at:

All information disclosed in this proposal will remain confidential and will be used only for the purposes of evaluating the
viability of the business idea and the suitability of the applicant for the Self-Employment Benefit Program.
1. Briefly describe the product or service your business will provide.

2a. What skills and experience do you have that will help you operate this business?

2b. Identify the reasons for starting this business. Is self employment your best alternative at the present time?
If so indicate your reasons.

3a. Is there any specific skill or business training NDBDC could conduct that you feel would improve your
ability to operate the business? (i.e. basic computer skills, bookkeeping, Internet, networking, marketing,
advertising, time management, sales and cold calling skills etc.)

3b. Why is the SEB allowance needed? Please be specific.

4. Which competitors are providing an identical or similar product/service?

 Competitor Name                                                Location                Price Level

 What price level will your product/service be?

5. Describe how your product/service is unique and what you feel is your competitive advantage.

6. Who is your primary target market (intended customers)? What do you expect the size of the market to be?

7. Why do you think there is a need/demand for your product/service? What market research have you done
to date? What sort of response/feedback have you received from potential customers? How does this support
your decision to start this business?

8. How will you promote your product/service and what will be your promotional message to potential

9. What do you estimate are your total start up costs and where will the money come from?

10. Are there any environmental concerns associated with your business operations, and if so what are they?
Detail what you will do to comply with all applicable regulations.

11. Summarize why you think this business concept will succeed.


Home:    (___) _____________              Business Telephone:   ( ___ ) ____________
Mobile: (___) _____________                        Fax: ( ___ ) ____________
E-mail: ________________________________________________________________________________

Marital Status: ____________________     Number of Dependants (excl. spouse):   _____________

Municipal Ward #: _________________      Date of Birth: DD/MM/YY _____ / _____ / ________

Bank: ________________________________________ Contact: _____________________________

Legal Firm: ____________________________________ Contact: _____________________________

Accounting Firm: _______________________________ Contact: _____________________________

Start-up Funds required:                     Source of Funds:
Rent / lease / land                          Applicant Cash
Building / renovations                       Bank
Equipment                                    NDBDC
Inventory                                    Private
Working Capital                                 In kind:
-                                            -
-                                            -
-                                            -
-                                            -
-                                            -
TOTAL:                                       TOTAL:

Name (first/middle/last)                                                     SIN (optional)                   Date of Birth (dd/mm/yy)

Street Address / R.R.# /P.O. BOX                                Town                           Postal Code    Telephone Number

Name of Spouse                                                               SIN (optional)                   Date of Birth (dd/mm/yy)

Spouse’s Employer                                     Employer Address                                        Telephone Number

                           ASSETS                                                                    LIABILITIES
CASH & DEPOSIT ACCOUNTS                           $                      BANK LOANS                                            $

STOCKS / BONDS / RRSP’S                           $                      CREDIT CARDS                                          $

LIFE INSURANCE: NET CSV                           $                      LOANS AGAINST LIFE INSURANCE                          $

REAL ESTATE                                       $                      MORTGAGES                                             $

OTHER INVESTMENTS                                 $                      UNPAID INCOME TAX                                     $

VEHICLES                                          $                      UNPAID PROPERTY TAX                                   $

OTHER ASSETS                                      $                      OTHER LIABILITIES                                     $

 (A) TOTAL ASSETS                                 $                        (B) TOTAL LIABILITIES                               $

                                                                                                     NET WORTH     (A) - (B)   $

              ANNUAL INCOME (for next 12 months)                                       ANNUAL EXPENDITURES (for next 12 months)
                                       SELF                      SPOUSE               RENT / MORTGAGE PAYMENTS                 $
                             GROSS           NET         GROSS             NET
                                         (After Ded)                   (After Ded)    LOAN PAYMENTS                            $

SALARY, WAGES                      -          -                                       HEAT / HYDRO / TELEPHONE                 $

DIVIDENDS, INTEREST                                                                   PROPERTY / CONTENTS INSURANCE            $

RENTAL INCOME                                                                         LIFE INSURANCE                           $

BUSINESS INCOME                                                                       PROPERTY TAXES                           $

SEB ALLOWANCE                16,920        16,000                                     FOOD / CLOTHING                          $

OTHER INCOME                                                                          VEHICLE OPERATION & INSURANCE            $

                                                                                      RECREATION & EDUCATION                   $

TOTAL INDIVIDUAL                                                                      MISCELLANEOUS                            $

         TOTAL HOUSEHOLD INCOME                   NET    $                                    TOTAL ANNUAL EXPENDITURES        $

Additional Information:     1.         Are you liable as a co-signer or guarantor?                                  Yes       No   
                            2.         Are there or has there ever been any lawsuits or judgments against you?      Yes       No   
                            3.         Are you now or have you ever been bankrupt?                                  Yes       No   
                            4.         Are you in default of any amount owing to the federal government?            Yes       No   

1. I/we hereby certify that the information given in this personal financial statement is true, accurate and complete in all instances and
accurately reflects my financial situation as at the statement date.
2. I/we fully understand that such information shall be used to determine my credit worth. I authorize the NDBDC to obtain personal credit
information about me from any source. By executing this statement, I acknowledge as notice in writing, the NDBDC’s intent to obtain this
information and I authorize each source to provide this information to the NDBDC.
3. I/we understand that the NDBDC will handle my personal information in strict confidence in accordance with federal privacy law as set
out in the NDBDC’s Privacy Policy (available at the NDBDC office or on the website .

Signature: ____________________________________              Signature: ____________________________________        Date: _______________
           Applicant                                                    Spouse

I hereby certify that all the information given by me in this Business Concept Proposal and SEB Application
is accurate, complete, and true. I understand that any false information given may result in the denial of this
application and/or immediate dismissal from the SEB program.

I further understand that:
    Ontario Ministry of Training, Colleges, and Universities (MTCU) has final approval of my application
       to the SEB Program.
    I must work full-time (minimum 35 hours/week) at this proposed business venture
    the period of financial support is 40 calendar weeks from the commencement date and that the period
       of business advisory assistance is 52 weeks from the commencement date

I am solely responsible for the undertaking of this proposed business venture. I consent to the Norfolk
District Business Development Corporation or its agents making any inquiries of such persons, firms, or
corporation as it deems necessary in order to adequately assess the business venture and to confirm my
eligibility for benefits under the Employment Insurance Act.

I, the undersigned, by executing this statement, consent to my personal information being collected, used,
retained, and disclosed by the NDBDC for purposes of assessing eligibility for the NDBDC services,
communicating future NDBDC services, monitoring the progress of the business, and meeting legal and
regulatory requirements. I acknowledge receipt of the NDBDC’s Privacy Statement (see below) and hereby
consent to the use of my personal information as set out above.

_________________________________                                                               _________________________________
Name                                                                                            Signature

The Norfolk District Business Development Corporation (NDBDC) respects the privacy of its clients. In doing business with the NDBDC, you, the client, provide
information about yourself. This statement summarizes the NDBDC's privacy policy that has been developed to keep your information confidential and to protect your
privacy. It was developed to comply with Canada's Personal Information Protection and Electronic Documents Act ("PIPEDA"). PIPEDA sets out rules for the collection,
use and disclosure of a client's or customer's personal information, as well as safeguarding that information in the course of commercial activity as defined in the
WHAT IS "PERSONAL INFORMATION" "Personal Information" means any information that is identifiable to an individual, including name, address, telephone number,
Social Insurance Number, and date of birth. It also includes, but is not limited to, other information relating to identity, such as, nationality, gender, marital status, financial
information and credit history.
PURPOSES FOR PERSONAL INFORMATION The NDBDC collects only that personal information required to assess a prospective applicant's eligibility for services of
the NDBDC as well as to report to Industry Canada, the federal department that supports the objectives of the NDBDC.
CONSENT At the time of completing an application for consideration of a service at the NDBDC, the express, written consent of the individual applicant will be sought for
the collection, use, retention and disclosure of their personal information for the purposes set out in the NDBDC's privacy policy.
An applicant may choose not to provide some or all of the personal information requested, but if the NDBDC is unable to validate the information provided, the application
may be turned down.
ACCURACY The NDBDC endeavors to ensure that all personal information in active files is accurate, current and complete. An individual who wishes to review or verify
what personal information is held by the NDBDC, may do so by making a request, in writing to the NDBDC's Chief Privacy Officer. Upon verification of the individual's
identity, the Chief Privacy Office will provide a written report within 60 days. Information contained in closed files is not updated.
SAFEGUARDS The NDBDC utilizes a number of physical, organizational and technological measures to safeguard personal information from unauthorized access or
inadvertent disclosure.
INVESTIGATING COMPLAINTS Any concern or issue about the NDBDC personal information handling practices may be made, in writing, to the Chief Privacy Officer.
Upon verification of the individual's identity, the Chief Privacy Officer will act promptly to investigate the complaint and provide a written report to the individual.
If the individual is dissatisfied with the report provided by the Chief Privacy Officer, or feels that the corrective action taken by the NDBDC is insufficient, the individual
may direct a complaint to the Federal Privacy Commissioner in writing. The address of the Federal Privacy Commissioner is available in the NDBDC Privacy Policy
available at our office or on our website (
AMENDMENTS TO OUR PRIVACY POLICY Any amendments or updates to the NDBDC Privacy Policy or this Privacy Statement will be posted on the NDBDC website
and will apply to all personal information collected from the date of the posting of the revised documents.
For additional information, please contact the NDBDC office in Simcoe at 519-428-2323


Description: Blank Personal Financial Statement Template for Canada document sample