PERSONAL FINANCIAL QUESTIONNAIRE

Are you or your spouse self-employed (receive a form 1099) or do you operate a business?

Yes
No

Is the business a sole-proprietorship?

Yes
No

Name of Business

Employer Identification Number

Address of Business

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Telephone Number

Business Web Site

Trade Name or DBA

Description of Business

Total Number of Employees

Frequency of Tax Deposits

Average Gross Monthly Payroll

Is the business a Federal contractor?

Yes
No

Does the business engage in Internet sales?

Yes
No

Do you or your spouse have any other business interests? Include any interest in an LLC, LLP, Corporation, Partnership, etc.

Yes
No

If yes, what is the % of ownership and what is your title?

Business Asset Information (for self-employed)

Total Business Cash on Hand (Include any money that your business has that is not in a bank).

Account #1

Type of Account

Bank Name

Account #

Bank Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Current Balance ($)

Account #2

Type of Account

Bank Name

Account #

Bank Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Current Balance ($)

Other Assets

Do you have other assets?

Yes
No

Asset #1

Description of Asset #1

Purchase / Lease Date

Current Value ($)

Loan Balance ($)

Amount of Monthly Payment ($)

Date of Final Payment

Location of Asset

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Lender/Leaser/Landlord Name

Lender/Leaser/Landlord Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Asset #2

Description of Asset #2

Purchase / Lease Date

Current Value ($)

Loan Balance ($)

Amount of Monthly Payment ($)

Date of Final Payment

Location of Asset

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Lender/Leaser/Landlord Name

Lender/Leaser/Landlord Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Asset #3

Description of Asset #3

Purchase / Lease Date

Current Value ($)

Loan Balance ($)

Amount of Monthly Payment ($)

Date of Final Payment

Location of Asset

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Lender/Leaser/Landlord Name

Lender/Leaser/Landlord Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Income and Expense Information (for self-employed)

Please download profit and loss statement template as reference. DOWNLOAD

If self-employed, please attach a copy of profit and loss statement from accountant of accounting software (e.g. QuickBooks), if available. Otherwise, complete the following.

Statement of Income for the period (mm/dd/yyy to mm/dd/yyyy)

Business Income

Gross Receipts

Gross Rental

Interest Income

Dividends

Other Income

Business Expenses

Material Purchased

Inventory Purchased

Gross wages and salaries

Rent

Supplies (items used to conduct business and used up within one year, e.g. books, office, supplies, equipment, etc.)

Utilities/Telephone

Vehicle Costs (gas, oil, repairs, maintenance)

Business Insurance

Current Business Taxes (real estate, excise, franchise, occupational, personal property, sales)

Other secured debts (not credit cards)

Other Business Expenses

Accounting

Advertising

Bad Debts

Bank Charges

Commissions

Contract Labor

Delivery & Freight

Draws/Distributions

Dues & Subscriptions

Entertainment

Interest

Janitorial

Laundry & Cleaning

Legal & Professional

Licenses & Permits

Meals

Miscellaneous

Office Expense

Parking & Tolls

Postage

Printing

Promotion

Repairs

Security

Taxes - Payroll

Travel - Airfare, hotel, etc.

Uniforms

Total Expenses