Bonds Southeast, Inc. | Personal Financial Statement

Bonds Southeast, Inc.
Contract & Commercial Surety Bonds
1030 17th Avenue South
Nashville, TN 37212
(615) 321-9700
Toll Free: 1-877-992-6637
Fax: (615) 321-9702

Personal Financial Statement

Statement of Financial Condition As Of
Name of Applicant
Applicant's Social Security Number	- -
Applicant's Date of Birth
Name of Spouse
Spouse's Social Security Number	- -
Spouse's Date of Birth
Residential Address	Street CIty State Zip
Home Phone Number	( )

ASSETS

Cash in Banks
Notes Receivable
Accounts Receivable
Stocks/Bonds/Securities
Real Estate (Residence)
Real Estate (Investment/Other)
Cash Value Life Insurance
Personal Property
Other Assets
TOTAL ASSETS

LIABILITIES

Loans Payable (Banks)
Notes Payable
Accounts Payable
Taxes Payable
Mortgages Payable
Other Liabilities

TOTAL LIABILITIES
NET WORTH
Total Net Worth & Liabilities

INCOME

Applicant's Salary	$
Applicant's Bonus/Other	$
Spouse's Salary	$
Spouse's Bonus/Other	$
TOTAL INCOME	$

SUPPLEMENTARY SCHEDULES OF ASSETS & LIABILITIES
(NOTE: All data listed above must appear in the appropriate schedules. Insert "NONE" where appropriate.)

CASH IN BANKS:

Name of Bank	Branch / Location	Account #	Amount

NOTES & ACCOUNTS RECEIVABLE:

Debtor #1	Name Address Amount Due Date Pledged? Yes No Security
Debtor #2	Name Address Amount Due Date Pledged? Yes No Security
Debtor #3	Name Address Amount Due Date Pledged? Yes No Security

STOCKS / BONDS / SECURITIES:

Name of Stock, Bond or Security	No. of Shares	Price/Share	Market Value	Exchange & Call Sign

REAL ESTATE:

Item #1	Location / Description Year Acquired Cost Market Value Monthly Income Monthly Payment Mortgage Balance Mortgage or Lein Holder
Item #2	Location / Description Year Acquired Cost Market Value Monthly Income Monthly Payment Mortgage Balance Mortgage or Lein Holder
Item #3	Location / Description Year Acquired Cost Market Value Monthly Income Monthly Payment Mortgage Balance Mortgage or Lein Holder

CASH VALUE OF LIFE INSURANCE:

Name of Insurance Company	Beneficiary	Face Value	Cash Value	Loans Outstanding

OTHER ASSETS:

Description	Title Holder	Cost	Market Value	Age of Asset

LOANS PAYABLE

Name of Lender	Address	Balance Due	Amount Due in 1 Year	How Secured

ACCOUNTS & NOTES PAYABLE (Including Charge Accounts):

Payable to Whom	Address	Amount	Monthly Payment	Due Date	How Secured

TAXES PAYABLE (State & Federal):

Description	Amount	Date Payment is Due

OTHER LIABILITIES:

Description	Payable To:	Amount	Monthly Payment	Due Date	How Secured

Are you contingently liable or an endorser on any bonds or other obligations?	Yes No
Are you involved in any litigation?	Yes No
Have you filed for bankruptcy in the last 7 years?	Yes No

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