State Of Maryland Department of Labor, Licensing And Regulation
Maryland Home Improvement Commission
500 N. Calvert St.
Baltimore, Maryland 21202-3651
Room 306
410-230-6231 (Baltimore area) or 1-888-218-5925 (toll free)

Personal Financial Statement


Name S.S# Date

CURRENT ASSETS

Cash and Securities:

Name and Location of Bank
Deposits

1.

$
 




2.

$
 




3.

$
 




Submit copy of last 3 months personal bank statements

Stocks, Bonds, and other securities
$
(Submit current market value and proof of value):

Total Cash and Securities:
$


Real Estate (Give locations and appraised value, attach Tax Assesment Notice. Provide deed, if out of state. If jointly owned, attach co-owners affidavit.):

1.

$
 




2.

$
 




3.

$
 




Total Real Estate:
$


Other Assets (Submit proof of value):

1.

$

2.

$

3.

$

Total Other Assets:
$


Total Assets
$

CURRENT LIABILITIES

 Amounts Payable to Banks, Credit Cards and Others:
 
Lender
Balance Due
1.
$
2.
$
3.
$
4.
$
5.
$
6.
$
Total Amount Due
$
Total Past Due
$


Income Taxes (unpaid balance):

 Federal
$
 State $
 Total Taxes $


Open Judgements or Liens (Show date and description on separate page.):
1. $
2. $
Total $


Fixed Liabilities Borrowed or Due on Real Estate

 
Mortgage Holder Balance Due

 1.

$
 2.
$
 3.
$

Total Mortgages: 
$


Other Liabilities:

 1.

$
 2.
$
 3.
$

Total Other Liabilities: 
$


Net Worth (assets minus liabilities):
Total Assets $
Total Liabilities $
Net Worth $

I hereby certify, under penalty of perjury, that the information contained herein is true and correct to the best of my knowledge, information and belief. I further authorize the release of any financial information contained within this application to an authorized representative of the Department of Labor, Licensing and Regulation for further investigation. I further certify that I have paid all undisputed taxes and unemployment insurance contributions payable to the Comptroller or the Department of Labor, Licensing and Regulation or have provided for payment in a manner satisfactory to the unit responsible for collection. tents of this document are true and correct.

Name
Signature
Date