Personal Net Worth Statement Form - New York
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NEW YORK STATE DEPARTMENT OF TRANSPORTATION
Contract A udi t Bureau DBE Cert i fi cat i on Te am
50 Wolf Road, 1
st
Floor South
Albany, New Yo rk 12 23 2
STATEMENT OF PERSONAL NET WORTH
As of __________________, __________
Complete this form for: (1) each socially disadvantaged owner; (2) each socially disadvantaged limited and general partner whose combined
interest totals 51% or more; or (3) each socially disadvantaged stockholder whose combined interest totals 51% or more of voting stock.
Name Business Phone:
Residence Address Residence Phone:
City, State & Zip Code
Business Name of Applicant
ASSETS
(Omit Cents)
LIABILITIES
(Omit Cents)
Cash on hand & in Banks . . . . . . . . . . . . . . . . $
Accounts Payable . . . . . . . . . . . . . . . . . . . . .
(Describe in Section 7)
$
Savings Accounts . . . . . . . . . . . . . . . . . . . . . . $ Notes Payable to Bank and Others . . . . . . . . $
IRA or Other Retirement Account . . . . . . . . . . $ (Describe in Section 2)
Accounts & Notes Receivable . . . . . . . . . . . . . $
Installment Account (Auto) . . . . . . . . . . . . . . .
(Describe in Section 7)
$
Life Insurance-Cash Surrender Value Only. . $ Mon. Payments $ _________________
(Complete Section 8) Installment Account (Other) . . . . . . . . . . . . . . $
Stocks and Bonds . . . . . . . . . . . . . . . . . . . . . . $ Mon. Payments $ ____ _____________ _
(Describe in Section 3) Loan on Life Insurance . . . . . . . . . . . . . . . . . . $
Real Estate . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Mortgages on Real Estate . . . . . . . . . . . . . . . $
(Describe in Section 4) (Describe in Section 4)
Automobile-Present Value . . . . . . . . . . . . . . . $ Unpaid Taxes . . . . . . . . . . . . . . . . . . . . . . . . . $
Other Personal Property . . . . . . . . . . . . . . . . $ (Describe in Section 6)
(Describe in Section 5) Other Liabilities . . . . . . . . . . . . . . . . . . . . . . . . $
Other Assets . . . . . . . . . . . . . . . . . . . . . . . . . $ (Describe in Section 7)
Total Liabilities . . . . . . . . . . . . . . . . . . . . . . . . $
Net Worth . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Total
$
Total
$
Section 1. Source of Income Contingent Liabilities
Salary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ As Endorser or Co-Maker . . . . . . . . . . . . . . . . $
Net Investment Income . . . . . . . . . . . . . . . . . . . . $ Legal Claims & Judgments . . . . . . . . . . . . . . . $
Real Estate Income . . . . . . . . . . . . . . . . . . . . . . . $ Provisions for Federal Income Tax . . . . . . . . . $
Other Income (Describe below)* . . . . . . . . . . . .
.
$ Other Special Debt . . . . . . . . . . . . . . . . . . . . . $
Description of Other Income in Section 1.
*Alimony or child support payments need not be disclosed in “Other Income” unless is desired to have such payments counted toward total income.
Section 2. Notes Payable to Banks and Others (Use attachments if necessary. Each attachment must be identified as part of this statement and.
signed.).
Name and Address of Noteholder(s)
Original
Balance
Current
Balance
Payment
Amount
Frequency
(monthly, etc .)
How Secured or Endorsed
Type of Collateral
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