Personal Financial Statement Personal Financial Statement as of: Month Day Year Applicant's Name First Last Co-Applicant's Name (if applicable) First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhonePersonal Email Are you a defendant in any suits or legal action? Yes No If yes, explain below. Have You Ever Declared Bankruptcy? Yes No If yes, explain below. Number of DependentsAges of Dependents. Work InformationEmployer Profession How Many Years Have You Been in this Profession?Work Email Work PhoneAre Any Assets Pledged? If yes, list. Financial InformationPlease Enter All Information in US Dollars ($).AssetsCash on Hand and in BanksMarketable SecuritiesOther Equity InterestsRetirement Accounts (401K, Sep IRA, etc.) Add RemoveAssets, cont.Real Estate OwnedAccounts, Loans, & Notes ReceivableCash Value of Life InsuranceEquity in LLC's, S-Corp's or Other Businesses Add RemoveOther AssetsCars & TrucksMotor HomeAntique CardsPersonal Property Add RemoveLiabilitiesNotes Payable - Banks and Other InstitutionsAccounts and Bills DueUnpaid TaxesMortages Payable Add RemoveOther Liabilities Add RemovePlease list any other liabilities and the amount(s).Sources of IncomePlease Enter All Information in US Dollars ($).Main Income (Monthly)SalaryBonus and CommissionsDividends and InterestsReal Estate Income Add RemoveOther Income: Please Itemize (Monthly) Add RemovePlease list other sources of income and the amount.AccountsCredit Card and/or Loan DebtName of InstitutionName on AccountCredit LimitOutstanding Balance Add RemoveList here the names of all the institutions at which you maintain a credit card and/or loan account.Bank Account InformationName of InstitutionName on AccountChecking or SavingsCash Balance Add RemoveList here the names of all the institutions at which you maintain a savings or checking account.Stocks/Bonds/EquitiesName of BrokerageName on AccountCash Balance Add RemoveList here the accounts in which you have stocks, bonds, or any other form of equities.Real Estate Owned (and related debt, if applicable)Property Address or DescriptionTitle in the Name ofDate AcquiredPresent Market ValueBalance OwedMonthly Payment (if any) Add RemoveEquity in Other BusinessesBusiness Name% of OwnershipValuation Add RemoveList here the names of all the institutions at which you maintain a savings or checking account.Please list any loans or payment requirements that are delinquent or in default.Loan NameAmount Owed Add RemoveList here the names of all the institutions at which you maintain a savings or checking account.Agree, Sign and SubmitI/We have carefully read and submitted the foregoing information provided on all three pages of this statement to Nora Mental Health. The information is presented as a true and accurate statement of my/our financial condition on the date indicated. I/We agree that if any material change(s) occur(s) in my/our financial condition that I/we will immediately notify Nora Mental Health of said change(s) and unless Nora Mental Health is so notified it may continue to rely upon this financial statement and the said representations made herein as a true and accurate statement of my/our financial condition. Agree I/We fully understand that it is a federal crime punishable by fine or imprisonment or both to knowingly make any false statements concerning any of the above facts, pursuant to 18 U.S.C. Section 1014. Agree Applicant's E-Signature First Last DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.Co-Applicant's E-Signature (if applicable) First Last DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
