Personal Worth Statement Form PDF Details

In the landscape of financial declarations, the Personal Net Worth Statement form emerges as a pivotal document, particularly for socially disadvantaged individuals aiming to establish their economic status within specific legal or business contexts. This comprehensive form necessitates detailed information on both assets and liabilities, excluding the individual's ownership interest in the application business and their personal residence, to precisely calculate net worth. It faithfully records various financial components such as cash holdings, savings accounts, retirement accounts, real estate (excluding personal residences), automobiles, and more, against liabilities like accounts payable, notes payable, mortgages (excluding that of the personal residence), and unpaid taxes. Interestingly, in marital scenarios, only half of the marital assets are considered. The form also delves into contingent liabilities and other sources of income, offering a holistic view of an individual's financial standing. A crucial section mandates disclosure of any asset transfers within the prior two years, spotlighting the transparency and honesty expected in these declarations. Completing this form not only requires a detailed disclosure of financial positions but also an affidavit affirming the veracity of the provided information, underlining the serious legal undertones of the exercise. This document stands as a vital tool for socially disadvantaged proprietors, partners, and stockholders, guiding them through the meticulous process of legal and financial self-assessment.

QuestionAnswer
Form NamePersonal Worth Statement Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namespersonal net worth statement, net worth statement definition, worth statement statements, net worth statement format

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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

Business Phone (

)

PERSONAL FINANCIAL STATEMENT

As of (Date)___/___/_____. 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 $__________________________

Savings Accounts

$__________________

Notes Payable to Banks and Others $_____________

 

 

(Describe in Section 1)

IRA or Other Retirement Account $_________________

 

 

 

Installment Account (Auto) $____________________

Accounts and Notes Receivable $__________________

 

 

 

Installment Account (Other) $___________________

Life insurance -

$___________________

 

Cash Surrender Value Only

(Complete Section 7)

Loan on Life Insurance $_______________________

Stocks and Bonds

$___________________

Mortgages on Real Estate $_____________________

 

(Describe in Section 2)

[Except for Personal residence] (Describe in Section

 

 

3)

Real Estate

$___________________

 

[Except for personal Residence] (Describe in Section 3)

Unpaid Taxes $____________________________

 

 

(Describe in Section 5)

Automobile(s) – Present Value

$__________________

 

 

 

Other Liabilities $___________________________

Other Personal Property

$__________________

(Describe in Section 6)

 

(Describe in Section 4)

 

Other Assets

$___________________

Total Liabilities $___________________

 

 

(Describe in 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 $________________

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

Name and Address of Note Holders (s)

Original Balance

Current Balance

Payment Amount

Frequency (weekly, monthly, etc.)

How Secured or Endorsed Type 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

Name of Securities

Cost

Market Value Quotation or Exchange

Date of Quotation or Exchange

Total Value

Section 3. Real Estate Owned. (Do not include your personal resident. 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

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 that market value of the assets as 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 is 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 release to any person, governmental or commercial entity without the written permission of the person submitting the information.

PERSONAL NET WORTH AFFIDAVIT

The undersigned swears/affirms 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 entities of the Texas Unified Certification Program (TUCP) and/or U.S. Department of Transportation (DOT) as part of this certification process and 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 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 individuals. 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)__________________________with proper

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

 

(SEAL)

_______________________

_____________________

Notary Public

Commission Expiration

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When it comes to blank fields of this specific form, here's what you need to know:

1. Fill out the personal networth statements with a selection of major blanks. Note all of the information you need and be sure absolutely nothing is omitted!

personal worth statement writing process detailed (step 1)

2. Once the previous part is finished, you have to insert the essential details in Cash on hand and in bank Savings, Other Source of Income, SalaryCommissions Net Investment, and Accounts Payable Notes Payable to so you're able to go to the third step.

personal worth statement completion process outlined (step 2)

3. The following segment focuses on Frequency weekly monthly etc, How Secured or Endorsed Type of, Section Stocks and Bonds Use, Number of Shares, Name of Securities, Cost, Market Value Quotation or Exchange, Section Real Estate Owned Do not, Property A, Property B, Type of Property, Date of Quotation or Exchange, Total Value, and Property C - fill in all these blank fields.

personal worth statement writing process detailed (portion 3)

Always be really attentive when completing Property B and Section Stocks and Bonds Use, as this is where most users make mistakes.

4. All set to proceed to this next section! In this case you'll have all of these 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, MonthYear, Status of Mortgage, and Property C blank fields to fill out.

Filling in section 4 of personal worth statement

5. Because you get close to the completion of your document, there are actually a couple more things to do. Specifically, Section Other Personal Property, Section Unpaid Taxes Describe in, Section Other Liabilities, and Section Life Insurance Held Give should all be filled out.

personal worth statement completion process clarified (part 5)

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