State Of Maryland Department of Labor
Maryland Home Improvement Commission
100 S. Charles St, Tower 1, 3rd Floor
Baltimore, Maryland 21201
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 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 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