Form 2099 PDF Details

Form 2099, revised in May 2011, serves as a comprehensive Personal Net Worth Statement designed specifically for individuals seeking to establish their status as socially disadvantaged for business purposes. This form mandates detailed reporting from proprietors, partners, and stockholders who classify as socially disadvantaged and hold a 51% or more interest in a business. By carefully distinguishing between personal and business assets, the form ensures an accurate representation of an individual's net worth. It requires the exclusion of both the individual's personal residence and any ownership interest in the applying business, thereby focusing solely on personal financial strength. Contributions to the net worth calculation include cash, retirement accounts, real estate (excluding personal residence), automobiles, personal property, and any other significant assets. Conversely, liabilities encompass personal debts ranging from payable accounts and notes to mortgages on real estate and unpaid taxes. The form goes further to detail income sources outside of business operations and any contingent liabilities, thereby providing a well-rounded financial profile. Additionally, it addresses potential asset transfers to prevent misuse of disadvantaged status qualifications. The form's stringent requirements are underscored by a Personal Net Worth Affidavit, reinforcing the accuracy of the information provided under penalty of law, including significant fines and imprisonment for false declarations. Ultimately, Form 2099 stands as a pivotal document in the certification process for individuals claiming a socially disadvantaged status, governed by federal confidentiality laws to protect the personal information of the applicants.

QuestionAnswer
Form NameForm 2099
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesjointly, misrepresents, Endorser, deems

Form Preview Example

Form 2099 (Rev. 05/11)

Page 23 of 31

PERSONAL NET WORTH STATEMENT

Complete a form for: (1) each socially disadvantaged proprietor, or (2) each socially disadvantaged limited and general partner whose combined interest total 51% or more, or (3) each socially disadvantaged stockholder owning 51% or more of voting stock. An individual's personal net worth includes only his or her share of the assets held jointly or as community property with the individual's spouse.

Name:

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Residence Address:

 

 

 

 

 

 

 

 

Residence Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City, State & Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Business Name:

 

 

 

 

 

 

 

 

Residence Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONAL FINANCIAL STATEMENT

 

 

 

 

 

 

 

 

 

 

 

As of

___/___/___

 

 

 

. In determining net worth, EXCLUDE individual ownership interest in the applicant business

 

 

 

 

 

and personal residence. If married use only ½ of marital assets. Round all numbers to the nearest dollar.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ASSETS

 

 

 

 

 

 

 

 

LIABILITIES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cash on hand and in bank

$

 

Accounts Payable

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

Notes Payable to Banks and

 

 

 

 

Savings Accounts

 

 

 

$

 

$

 

 

 

 

 

 

Others

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Complete Section 1)

IRA or Other Retirement Account

$

 

 

Installment Account (Auto)

$

 

Accounts and Notes Receivable

$

 

 

 

 

 

 

 

 

 

 

 

 

Installment Account (Other)

$

 

Life Insurance -

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Loan on Life Insurance

$

 

Cash Surrender Value Only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Complete Section 7)

 

 

 

 

 

 

 

 

 

 

 

Stocks and Bonds

 

 

 

$

 

 

Mortgages on Real Estate

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[Except for personal residence]

 

 

(Complete Section 3)

 

 

 

 

 

 

 

 

 

(Complete Section 2)

Real Estate

 

 

 

$

 

Unpaid Taxes

 

 

 

 

$

 

 

[Except for personal residence]

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Complete Section 3)

 

 

 

 

 

 

 

 

 

(Complete Section 5)

Automobile(s) – Present Value

$

 

 

 

Other Liabilities

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Complete Section 6)

Other Personal Property

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Complete Section 4)

 

Total Liabilities

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Assets

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Complete Section 4)

 

 

 

 

 

 

 

 

 

 

 

Total Assets $

 

 

 

 

 

 

 

Net Worth

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Total Assets minus Total Liabilities)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Source of Income:

 

 

 

 

 

 

 

Other Contingent Liabilities:

 

 

 

 

Salary/Commissions $

 

 

 

 

 

 

 

As Endorser or Co-worker $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Net Investment Income

$

 

 

 

 

 

 

Legal Claims and/or Judgments

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form 2099 (Rev. 05/11)

Page 24 of 31

Section 1. Notes payable to Bank and Others (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)

Name and Address of Note Holders

Original

Current Balance

Payment

Frequency

How Secured or

 

Balance

 

Amount

(weekly,

Endorsed; Type

 

 

 

 

monthly, etc.)

of Collateral

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 2. Stocks and Bonds. (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.) NOTE: Must be within five (5) days of statement date.

Number of Shares

Original Balance

Cost

Market Value

Date of

Total Value

 

 

 

Quotation or

Quotation or

 

 

 

 

Exchange

Exchange

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 3. Real Estate Owned. (Do not include your personal residence. List each parcel separately. Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)

Property A

Property B

Property C

Type of Property

Address

Date Purchased

Original Cost

Present Market Value

Name and Address of Mortgage Holder

Mortgage Account Number

Mortgage Balance

Amount of Payment per

Month/Year

Status of Mortgage

Form 2099 (Rev. 05/11)

Page 25 of 31

Section 4. Other Personal Property and Other Assets. (Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms of payment, and if delinquent, describe.)

Section 5. Unpaid Taxes. (Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.)

Section 6. Other Liabilities (Describe in detail).

Section 7. Life Insurance Held. (Give face amount and cash surrender value of policies - name of insurance company and beneficiaries.)

Section 8. Transfer of Assets.

Have you, the individual claiming disadvantaged status, transferred any assets within two (2) years, in full or in part, to

a spouse or any other person or entity, including a trust?

 

Yes

 

No

If yes, provide the following information as an attachment: the date of transfer, to whom the assets were transferred, amount paid for the assets, the market value of the assets at the time of transfer.

NOTE: Individuals may exclude assets transferred to an immediate family member that are consistent with the customary recognition of special occasions and may also exclude any transfers to an immediate family member for educational, medical, or essential support purposes.

Please provide copies of complete personal income tax returns, including all schedules, W-2s, and 1099 forms. 49 CFR Part 26 and federal law classify all information submitted with this form as confidential. This form or its information cannot be released to any person, governmental or commercial entity without the written permission of the person submitting the information.

with proper

Form 2099 (Rev. 05/11)

Page 26 of 31

PERSONAL NET WORTH AFFIDAVIT

The undersigned swear/affirm that the foregoing information and statements are true and correct, including all material and information necessary to identify and explain the financial net worth of

(Name of Individual)

Further, the undersigned agrees to permit the TUCP and/or U.S. Department of Transportation (DOT) as part of this certification process to interview owners, principals, officers, and employees; and to audit or examine books, records, and files of the above named individual.

If at any time the TUCP or DOT has reason to believe that any person or firm has willfully and knowingly provided incorrect information or made false statements, your file may be referred to the General Counsel of DOT. The General Counsel may initiate debarment procedures in accordance with 41 CFR 1-1.604 and 12-1.062 and/or refer the matter to the Department of Justice under U.S.C. 1001, as the General Counsel deems appropriate.

NOTE: Under Title 18 U.S.C. Section 1001 and Title 15 U.S.C. Section 645, any person who misrepresents a firm's status as a small disadvantaged business concern; or makes false statements in order to influence the certification process in any way; or to obtain a government contract, shall be subject to fines of up to $500,000 and imprisonment of up to 10 years, or both.

The burden of proving the financial net worth is the individual's. The Agency reserves the right to request any additional information deemed necessary to determine if an individual is economically disadvantaged. Failure to provide requested information within the time specified is grounds for termination of the process.

Name

 

Signature

 

 

 

Title

 

Date

Date

 

State of

 

County of

On this day before me appeared (name)

identification, who being duly sworn, did execute the foregoing affidavit and did aver that he or she was properly authorized to execute this affidavit and did so as his or her free act/deed.

(Seal)

Notary Public

Commission Expiration

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false conclusion process described (part 1)

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Part number 2 for submitting false

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false completion process clarified (stage 3)

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Original Cost, Name and Address of Mortgage Holder, and Present Market Value inside false

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Section Other Personal Property, Section Life Insurance Held Give, and Section Other Liabilities of false

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