PERSONAL STATEMENT OF AFFAIRS

















FINANCIAL POSITION AS AT:
,20

ASSETS

CASH





LIQUID INVESTMENTS* (stocks, bonds, etc.)









RRSP’s





REAL ESTATE*







LIFE INSURANCE*



PRIVATE INVESTMENTS





OTHER ASSETS







Total assets:

LIABILITIES

BANK LOANS









CREDIT CARDS







MORTGAGES





INCOME TAXES



OTHER LIABILITIES (Accounts Payable*)









Total Liabilities :

Assets - Liabilities = Net Worth :

Total :

Indirect Liabilities* :

ANNUAL INCOME







Total Income :

ANNUAL EXPENDITURES







Total Expenditures :

*PLEASE SEE OVERLEAF FOR DETAILED BREAKDOWN

I HEREBY CERTIFY that all information provided is true and complete. I have no other undisclosed financial obligations and acknowledge the foregoing will be used to determine my creditworthiness. I authorize you to give to and obtain from persons with whom I have financial or other business dealings, and commercial and consumer reporting agencies, credit and other financially-related information about me. If I have supplied my social insurance number (SIN) in any application to you, you may treat my SIN as an integral part of that information and maintain it in your records about me. You may likewise use my SIN and communicate it and allow it to be communicated to those persons and agencies as an aid to identifying me. My deposit account may be charged with payments on the loan.

SIGNED AT:
this
day of
200


PERSONAL STATEMENT OF AFFAIRS

HAVE YOU HAD ANY JUDGEMENTS OR LEGAL PROCEEDINGS AGAINST YOU?

Yes

DO YOU HAVE ANY OTHER BUSINESS CONNECTIONS?

Yes


HAVE YOU EVER BORROWED FROM OTHER BANKS OR FINANCIAL INSTITUTIONS>

Yes

LIQUID INVESTMENTS — LISTED & UNLISTED STOCKS AND/OR BONDS OWNED

Option - 1







Option - 2







Option - 3








REAL ESTATE OWNED

Option - 1











Option - 2











Option - 3











Option - 4











Total Cost :

Total Maturity :

LIFE INSURANCE

Option - 1






Option - 2






SUPPORTING DETAILS OF ACCOUNTS RECEIVABLE

Option - 1






Option - 2






Total Amount :

Total Payment :

SUPPORTING DETAILS OF ACCOUNTS PAYABLE

Option - 1






Option - 2






Total Amount :

Total Payment :

INDIRECT LIABILITIES/GUARANTEES/ENDORSEMENTS

Option - 1




Option - 2




Total Amount Of Guarantee/Endorsement :

Organization that have accepted our plans

Some of Our Affiliates