HAMPTON ROADS BONDING
1080 Laskin Road, Suite 204
Virginia Beach, Virginia 23451
Phone (757) 491-1100/Fax (757) 491-3134
PERSONAL FINANCIAL STATEMENT
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PERSONAL FINANCIAL STATEMENT AS OF
_______________________________
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(Statement date should be concurrent
with company financial statement)
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| Name of Individual:
_____________________ Spouses Name: ________________________ |
SSN: ____________________
SSN: ____________________ |
| Residence Address: _________________________________________________________ Occupation: ______________________________________________________________ |
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ASSETS |
LlABIL1TIES |
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Cash in Bank |
S |
Loans Payable-Bank $ |
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Notes Receivable |
$ |
Note Payable |
$ |
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Accounts Receivable |
$ |
Accounts Payable |
$ |
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Government
Bonds & |
$ |
Taxes Payable |
$ |
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Real Estate-Homestead |
$ |
Mortgages Payable |
$ |
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Real Estate-Investment |
$ |
Other Liabilities |
$ |
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Cash Value Life Insurance |
$ |
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Other Assets |
S |
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Car-Household Furnishings |
$ |
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Total Liabilities |
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Net Worth |
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Total Assets |
$ |
Total liabilities
and Net |
$ |
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INCOME |
Salary |
$ |
Spouse's Salary |
$ |
TOTAL
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Bonus/Other |
$ |
Bonus/Other |
$ |
$ |
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SUPPLEMENTARY SCHEDULES
NOTE: All data listed above
must appear on the appropriate schedules.
Insert "none" where appropriate. Designate
if owned jointly.
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1. Cash in Bank |
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Name, Branch & Location of Bank |
Account Number |
Amount |
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2. Notes and Accounts Receivable |
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Name and Address |
Amount
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Due Date |
Security
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Pledged? |
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3. Bonds and Marketable Securities |
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Name of Security |
Exchange List
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No. of Shares |
Price Per Share
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Market Value |
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4. Real Estate |
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| Location/Description |
Year Acq’d
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Cost
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Market Value
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Monthly Income
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Monthly Payment |
Mortgage Balance
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Mortgage or Lien Holder |
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5. Cash Value Life Insurance |
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Name and Address |
Beneficiary
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Face Value |
Cash Value
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Amount of Loans Against |
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6. Other Assets |
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Description |
Title Holder
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Cost |
Market Value
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Age of Assets |
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7. Loans Payable |
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Name of Lender |
Address
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Balance Due
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$ Due in 1 Year
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How Secured? |
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8. Accounts and Notes Payable (including Charge Accounts) |
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Payable to Whom |
Address
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Amount
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Due Date
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How Secured? |
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9. Taxes Payable (Federal and State) |
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Description |
Amount |
Date Payment is Due |
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10. Other Liabilities |
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Description |
Payable to Whom
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Amount
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Due Date
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How Secured? |
| Are you contingently liable or 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 seven (7) years? __Yes* __No *Explain all YES answers on separate sheet of paper. |
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I hereby certify and declare that the above statement presents accurately my financial condition to the best of my knowledge and :belief and hereby authorize and request any person, firm or corporation to furnish any information requested by any Harleysville Insurance Company (hereinafter called "Surety") concerning any transaction with the undersigned; and the said Surety is authorized to obtain information to confirm this financial statement and may furnish copies of the foregoing statement and any. information which it now has or may hereafter obtain to other companies for the purpose of securing reinsurance or co-suretyshlp. ___________________________ ___________________________ Witness Signature ___________________________ ___________________________ Witness
Signature |