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31 <br />Confidential <br />Personal Financial Statement <br />Orange County Small Business Loan Program As of , 20 <br />Complete this form for: (1) each proprietor, or (2) each limited partner who owns 10% or more interest and each general partner, or (3) each stockholder <br />owning 10% or more of voting stock, or 4 any person or entity providing a guaranty on the loan. <br />Name <br />Business Phone <br />Residence Address <br />Residence Phone <br />City, State, & Zip Code <br />Business Name of Applicant /Borrower <br />ASSETS <br />(Omit Cents) <br />LIABILITIES <br />(Omit Cents) <br />Cash on hand and checking Account <br />$ <br />Accounts Payable <br />$ <br />Savings Accounts <br />$ <br />Notes Payable to Banks and Others <br />$ <br />Certificates of Deposit <br />$ <br />(Describe in Section 2) <br />Retirement Funds (eg. IRAs, 401K) <br />Accounts & Notes Receivable <br />Life Insurance- Cash Surrender Value <br />(Complete Section 8) <br />Securities — Stocks /Bonds /Mutual Funds <br />(Describe in Section 3) <br />Real Estate <br />(Describe in Section 4) <br />Automobile- Present Value <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />Installment Account (Auto) <br />Mo. Payments $ <br />Installment Account (Other) <br />Mo. Payments $ <br />Loan on Life Insurance <br />Mortgages on Real Estate <br />(Describe in Section 4) <br />Unpaid Taxes (Describe in Section 6) <br />Other Liabilities <br />$ <br />$ <br />$ <br />$ <br />$ <br />Other Personal Property <br />(Describe in Section 5) <br />Other Assets <br />(Describe in Section 5) <br />$ <br />$ <br />(Describe in Section 7) <br />Total Liabilities <br />Net Worth <br />$ <br />$ <br />$ <br />Total Assets <br />$ <br />Total <br />$ <br />Section 1. Source of Income <br />Contin ent Liabilities <br />Salary <br />$ <br />As Endorser or Co -Maker <br />$ <br />Net Investment Income <br />$ <br />Legal Claims & Judge <br />$ <br />Real Estate Income <br />$ <br />Provision for Federal Income Tax <br />$ <br />Other Income (Describe below)* <br />$ <br />Other Special Debt <br />$ <br />Description of Other Income in Section 1. <br />*Alimony or child support payments need not be disclosed in "Other Income" unless it is desired to have such payments counted toward total income. <br />Section 2. Notes Payable <br />(Use attachments if necessary. Each attachment must be identified as a part of <br />this statement and signed). <br />Name and Address of Noteholder(s) <br />Original <br />Current <br />Payment <br />Frequency <br />How Secured or Endorsed <br />Balance <br />Balance <br />Amount <br />(month) etc. <br />