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Personal Financial Statement

Sunday, September 05, 2010
Applicant Information
Applicant
Corporate Headquarters Address
Contact
Phone
Fax
Email
Business Type
Date of Inc.
State of Inc.
Equipment Location
Equipment Description
Equipment Cost
Supplier(s)
Phone/Fax

Bank References
Bank Name
Contact
Phone/Fax
Account Number
Bank Name
Contact
Phone/Fax
Account Number

Secured Credit Reference - List Two Largest Creditors
Name of Institution
Contact
Phone/Fax
Account Number
Name of Institution
Contact
Phone/Fax
Account Number

Supplier Reference - List Three Largest Suppliers
Name of Company
Contact
Phone
Fax
Name of Company
Contact
Phone
Fax
Name of Company
Contact
Phone
Fax

The following information must be provided for all privately-held companies regardless of the availability of a guarantee:

Principal/Guarantor(s)
Name
Title
Address
SSN
Name
Title
Address
SSN

Financial Information Required:

  1. Last three (3) year-end accountant prepared financial statements. If the financial statements are prepared on a compilation basis, the last three (3) corporate tax returns will be required.
  2. Latest available interim financial statements.
  3. Corporate Guarantor - Same financial information as required in A & B above.
  4. Personal Guarantor - Most current personal financial statement and past two (2) year personal tax returns.

By agreeing below, the undersigned, provides written instruction to Liberty Capital Group, Inc. ("LCG") or it's designees (and any assignee or potential assignee thereof) authorizing review of his/her personal credit profile from a national credit bureau. Such authorization shall extend to obtaining a credit profile in considering this application and subsequently for the purpose of update, renewal or extension of such credit or additional credit and for reviewing or collecting the resulting account. A facsimile copy of this authorization shall be valid as the original. By signing below I/we affirm my/our identity as the respective individual/s identified in the above application. We hereby authorize the release of information requested by LCG regarding our bank, secured and trade relationships. The undersigned acknowledges that this is an application only and shall not be binding upon either party. However, it is understood, that LCG, may rely upon the accuracy of the information set forth herein and in the financial statements submitted herewith to provide financing to the undersigned.


Signed By: Title: Date:
Signed By: Title: Date:
 
 I / We agree to the terms and conditions above.
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Click Here to download this application form (PDF).