Bonding: Personal Financial Statement

PERSONAL FINANCIAL STATEMENT
This statement and any applicable schedules may be completed jointly by married and unmarried applicants if their assets and liabilities are sufficiently joined so that the statement can be meaningfully and fairly presented on a combined basis, otherwise separate statements and schedules are required.
Name*
First Last
Email*
Applicant is:
- Married
- Single
- Separated
If married, the financial statement is:
- Completed jointly with spouse
- Not completed jointly
Name of Spouse
First Last
Address
Street Address Address Line 2 City State ZIP Code
Statement of assets and liabilities as of:
Month
Day
Year

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ASSETS
Cash
Stocks, bonds, etc.
Accounts receivable
Notes receivable
Inventory
Equipment
Home
Real estate
Personal property
IRA
Other assets
TOTAL ASSETS
SOURCES ON INCOME FOR YEAR ENDED
Alimony, child support or separate maintenance income need not be As endorses, co-maker, or guarantor? $ revealed if you do not wish to have it considered as a basis for bonding.
Salary, bonuses & commissions
Dividends
Real estate income
Other income
TOTAL SOURCE ON INCOME FOR YEAR ENDED

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INSURANCE CARRIED
Fidelity Bonds on Officers & Employees
Life $
Property $
General Liability $
Other $
A. Bank Data
Name & Location of Bank Account Number Amount of Deposit In Whose Name Owed to Bank Date Due
Attach copy of bank data statements
Drop files here or

Accepted file types: pdf, Max. file size: 50 MB.
PDF only
B. Stocks, Bonds, Etc
Name of Security No. Shares Par Value Market Value In Whose Name Registered? If pledged, to whom & for what purpose?
Attach copy of stock/bond statements
Drop files here or

Accepted file types: pdf, Max. file size: 50 MB.
PDF only
C. Accounts Receivable & Payable
From Whom Due Amount Date Due To Whom Due Amount Date Due
D. Notes Receivable & Payable
From Whom Due Amount Date Due To Whom Due Amount Date Due
E. Inventory
Description Cost Price Market Value
F. Equipment
Description Cost Price Depreciation Charged Off Book Value Encumbrance Amount payable Monthly
G. Real Estate
Location & Description In Whose Name is Title Cost Present Forced Sale Value Amount of Mortgage Name of Mortgagee
H. Other Assets & Liabilities
Description of Other Assets Amount Description of Other Liabilities Amount

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Statement Execution
The undersigned furnished the foregoing as a true and accurate statement of the undersigned’s financial condition as of the date given. Starkweather & Shepley Insurance Brokerage, Inc. may furnish copies of the foregoing statement and any information which it has now or may hereinafter obtain, for the purposes of securing bonds, reinsurance, or co-insurance.
Date Signed
Month
Day
Year
Signature
Title
TERMS OF ACCEPTANCE and SIGNATURE*
- I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
I, the [applicant, requestor, etc.] for this personal financial statement, warrant the truthfulness of the information provided in this application.
S.S. Number
Date of Birth
Month
Day
Year
Spouse's Signature
Spouse's S.S. Number
Spouse's Date of Birth
Month
Day
Year
TERMS OF ACCEPTANCE and SIGNATURE
- I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
I, the [applicant, requestor, etc.] for this personal financial statement, warrant the truthfulness of the information provided in this application.
Approval
- I consent to my submitted data being collected and stored

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PERSONAL FINANCIAL STATEMENT

Name & Location of Bank	Account Number	Amount of Deposit	In Whose Name	Owed to Bank	Date Due

Name of Security	No. Shares	Par Value	Market Value	In Whose Name Registered?	If pledged, to whom & for what purpose?

From Whom Due	Amount	Date Due	To Whom Due	Amount	Date Due

From Whom Due	Amount	Date Due	To Whom Due	Amount	Date Due