Personal Net Statement Form PDF Details

Navigating the landscape of business certification, especially for minority and women-owned enterprises (MBE/WBE), necessitates the submission of various crucial documents, one of which is the Personal Net Statement form. This comprehensive document, revised last on August 23, 2012, by Cook County, plays a pivotal role for applicants aiming for certification or re-certification within the MBE/WBE Certification Program. The form requires detailed personal and financial information from the qualifying owner(s) of the applicant firm, including assets and liabilities ranging from cash, savings, real estate, and personal property, to debts and unpaid taxes. It goes further to request details on income sources, contingent liabilities, and even life insurance policies, creating a full picture of the applicant's financial standing. As part of the application process, this form not only assists Cook County in evaluating the financial health and integrity of businesses but also ensures that the benefits of certification are extended to those who meet the program's criteria. Applicants must understand the importance of accuracy and honesty in completing this form, as any misrepresentation can lead to severe consequences, including denial of certification or legal action. This document, signature-required and underlined by the seriousness of its assertions, becomes a declaration of financial transparency and integrity, essential for fostering credibility and trust within the MBE/WBE certification framework.

QuestionAnswer
Form NamePersonal Net Statement Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespersonal net statement pdf, personal net statement, cook county personal net worth statement, cook personal worth statement

Form Preview Example

Cook County

Personal Net Worth Statement

Revised 08/23/12

Cook County MBE/WBE Certification Program

As of (Insert Date):

 

 

 

For applicants applying to the County of Cook Certification or Re-Certification as MBE, and/or WBE, the qualifying owner(s) of the Applicant firm must complete this form.

Business Name

 

 

 

 

 

 

 

 

 

 

 

 

Owner Name

 

 

 

 

 

Business Phone

 

 

 

 

 

Residence Address

 

 

 

 

 

Residence Phone

 

 

 

 

 

City, State, & Zip Code

 

 

 

 

 

Email

 

 

 

 

 

 

ASSETS

 

 

 

 

 

 

LIABILITIES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cash on hand and in Banks

 

$

 

 

Accounts Payable

 

 

 

 

$

 

 

 

 

 

 

 

 

 

Savings Account

 

$

 

 

Notes Payable to Banks and Others (Describe in Section 2)

$

 

 

 

 

 

 

 

 

 

 

 

 

IRA or Other Retirement Account

 

$

 

 

Installment Account (Auto)

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

Accounts and Notes Receivable

 

$

 

 

Monthly Payments

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Life Insurance– Cash Surrender Value (Describe in Section 8)

$

 

 

Installment Account (Other)

 

$

 

 

 

 

 

 

 

 

 

 

 

 

Stock and Bonds (Describe in Section 3)

 

$

 

 

Monthly Payments

$

 

 

 

 

Real Estate (Describe in Section 4)

 

$

 

 

Loan on Life Insurance

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

Automobile – Present Value

 

$

 

 

Mortgages on Real Estate

 

$

Other Personal Property (Describe in Section 5)

 

$

 

 

Unpaid Taxes (Describe in Section 6)

 

$

 

 

 

 

 

 

 

 

 

 

Other Assets (Describe in Section 5)

 

$

 

 

Other Liabilities (Describe in Section 7)

 

$

 

 

 

 

 

 

TOTAL LIABILITES

 

 

 

 

$

TOTAL ASSETS

 

$

 

 

NET WORTH (Assets - Liabilities = NET WORTH)

$

 

 

 

 

 

 

 

 

 

 

 

 

Section 1. Source of Income

 

 

 

 

Contingent Liabilities

 

 

 

 

 

Salary

 

$

 

 

As Endorser of Co-Maker

 

 

 

 

$

Net Investment Income

 

$

 

 

Legal Claims and Judgments

 

$

 

 

 

 

 

 

 

 

 

 

Real Estate Income

 

$

 

 

Provisions for Federal Income Tax

 

$

Other Income (Describe below)*

 

$

 

 

Other Special Debt

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

Description of Other Income in Section 1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Alimony or child support payments need not be disclosed in “Other Income” unless it is desired to have such payments counted towards total income

 

 

 

 

 

Section 2. Notes Payable to Banks and Others (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)

 

 

Name & Address of Noteholder(s)

Original Balance

Current Balance

 

Payment Amount

 

Frequency

 

How Secured or Endorsed Type

 

 

 

 

 

 

 

(monthly, etc.)

 

 

of Collateral

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 3. Stocks and Bonds (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)

Number of Shares

Name of Securities

Cost

Market Value

Quotations/Exchange

Date of Quotations/Exchange

Total Value

Section 4. Real Estate Owned (List each parcel separately. Use attachment if necessary. Each attachment must be identified as part of this statement and signed.)

Property A

Property B

Property C

Type of Property

Address

Date Purchased

Original Cost

Present Market Value

Name & Address of Mortgage Holder

Mortgage Account Number

Mortgage Balance

Amount of Payment per Month/Year

Status of Mortgage

Section 5. Other Personal Property and Other Assets (Describe, and if any is pledges as security, state name and address of lien holder, amount of lien, terms of payment and if delinquent, describe delinquency)

Section 6. 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 7. Other Liabilities (Describe in detail)

Section 8. Life Insurance Held (Give face amount and cash surrender value of policies - name of insurance company and beneficiaries)

I authorize the County of Cook to make inquiries as necessary to verify the accuracy of the statements made. I certify the above and the statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of obtaining certification as a Minority, Woman and/or Veteran Owned Business Enterprise. I UNDERSTAND ANY MATERIAL MISREPRESENTATION OF INFORMATION IN THIS DOCUMENT MAY RESULT IN: 1.) DENIAL OF CERTIFICATION; 2.) DE-CERTIFICATION; 3.) TERMINATION OF ANY

CONTRACT AWARDED; 4.) DENIAL OF MBE/WBE/VBE PARICIPATION CREDIT; AND/OR INITIATION ACTION UNDER FEDERAL, STATE OR LOCAL LAW.

Signature:

Date:

SSN:

Signature:

Date:

SSN:

How to Edit Personal Net Statement Form Online for Free

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This PDF doc will involve some specific information; to ensure accuracy, you need to adhere to the tips below:

1. Whenever filling out the personal net statement printable, make certain to include all of the important blank fields in its relevant section. This will help hasten the work, enabling your information to be handled efficiently and correctly.

Step # 1 for filling out cook personal net worth statement

2. Once your current task is complete, take the next step – fill out all of these fields - Other Assets Describe in Section, TOTAL LIABILITES, TOTAL ASSETS NET WORTH Assets, Section Source of Income, Salary As Endorser of CoMaker, Net Investment Income Legal Claims, Real Estate Income Provisions for, Other Income Describe below Other, Description of Other Income in, Alimony or child support payments, and Name Address of Noteholders with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Filling in section 2 of cook personal net worth statement

3. Completing Section Stocks and Bonds Use, Section Real Estate Owned List, Type of Property, Address, Date Purchased, Original Cost, Present Market Value, Name Address of Mortgage Holder, Mortgage Account Number, Mortgage Balance, and Amount of Payment per MonthYear is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Completing part 3 of cook personal net worth statement

4. The next part will require your attention in the following places: Status of Mortgage, Section Other Personal Property, Section Unpaid Taxes Describe in, Section Other Liabilities, and Section Life Insurance Held Give. Be sure that you provide all of the needed info to move further.

Step number 4 for submitting cook personal net worth statement

5. Since you get close to the completion of this document, there are a couple more requirements that need to be fulfilled. Notably, Signature Date SSN, and Signature Date SSN must be done.

Signature Date SSN, Signature Date SSN, and Signature Date SSN inside cook personal net worth statement

Be very careful while filling in Signature Date SSN and Signature Date SSN, since this is the part in which many people make errors.

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