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Personal Financial Statement
Individual Information
First Name
*
Last Name
*
Email
*
Other Names Used:
Are you a US Citizen?
Yes
No
Alien Registration Number
Social Security Number
Date of Birth
Are you married?
Yes
No
Spouse Information
Spouse First Name
*
Spouse Last Name
*
Other Names Used:
Social Security Number
Spouse DOB
Are you a US Citezen?
Yes
No
Alien Registration Number
Address 1
Address 2
City
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Zipcode
Name of Businss
Relationship To Business
Owner
Shareholder
Family
Member
Employee
LLC Member
Other
Relationship To Business
Employment Information
Are you Employed?
Yes
No
Will employment continue if you get a loan?
Yes
No
Name of Employer
Employer Address
How long have you been employed here?
Spouse Employment Info.
Are you Employed? (Spouse)
Yes
No
Will employment continue if you get a loan?(Spouse)
Yes
No
Name of Employer (Spouse)
Employer Address (Spouse)
How long have you been employed here? (Spouse)
Financial Survey
Are you or your spouse presently under indictment, on parole, or probation?
Yes
No
Please explain and indicate when the parole or probation is to expire
Have you or your spouse ever been charged with, and/or arrested, for any criminal offense other than a minor motor vehicle violation?
Yes
No
Please Explain
Have you or your spouse ever been convicted, placed on pretrial diversion, or placed on any form of probation for a criminal offense other than a minor vehicle violation?
Yes
No
Please explain
Are you, your spouse, or an affiliate business, involved in any pending lawsuits?
Yes
No
Please explain
Have you or your spouse ever been involved in bankruptcy or insolvency proceedings?
Yes
No
Please explain
Are you, your spouse, or any member of your household, an employee of the City of Los Angeles, Small Business Administration, Small Business Advisory Council, SCORE, ACE, any government agency or potential lending institution?
Yes
No
Please explain
Do you or your spouse own or, have controlling interest, in a business other than the applicant business on this loan request?
Yes
No
What is the name of the affiliate business, what percentage ownership is held, and please describe the affiliate business AND you/your spouse's involvement in it.
Have you or your spouse received any student loans?
Yes
No
Please indicate status of loan (i.e.: paid, current, deferred, defaulted):
Do you or your spouse hold any assets in a trust?
Yes
No
Is it revocable? (Please be prepared to provide a copy of the trust agreement.)
In the past 12 months, have you been, or are currently delinquent or in arrears with your real estate taxes?
Yes
No
Please explain what is your current status and actions taken to resolve the issue?
Are you now more than 60 days delinquent in child support payments?
Yes
No
Please explain what is your current status and actions taken to resolve the issue?
Personal Assets
Cash
Retirement Account(s)
Investment Account(s)
Stocks & Bonds
Real Estate
Owned Vehicle(s) - Do Not List Leases
Other Assets: Please total
Personal Liabilities
Credit Card Balance(s)
Unpaid/Past Due Taxes
Student Loan(s)
Vehicle Loan(s)
Mortgage Loan(s)
Other Installment Debt(s)
Other Liabilities: Please total
Submit
Home
About Us
Best Buy Teen Tech Center
Job Opportunities + Requests for Proposals
Commercial Industrial Development
Annual Report
Best Buy Teen Tech Center
Lending
Success Stories
Get Started!
Calendar
Contact
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