Fillable Printable Personal Net Worth Statement Form - New York
Fillable Printable Personal Net Worth Statement Form - New York
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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Section 3. Stocks and Bonds. (Use attachments if necessary. Each attachment must be identified as a part of this stat ement and signed) .
Number of
Shares
Nam e of Secur ities Cost
Market Value
Quotation/Exchange
Date of
Quotation/Exchange
Total Value
Section 4. Real Estate Owned. (List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part of this
statement and signed. Do NOT include your primary residence.)
Property A Property B Property C
Type of Property
Address
Date Purchased
Original Cost
Present Market Value
Name &
Address of Mortgage Holder
Mortgage Account Number
Mortgage balance
Amount of Payment per month/Year
Status of Mortgage
Section 5. Other Personal Property and Other Assets. (Describe, and if any is pledged as security, state name and address of lien holder, amount
of lien, terms of payment and if delinquent, describe delinquency Ownership interest in affiliate firms must be included. Use attachments if
necessary).
Section 6. Unpaid Taxes. (Describe in detail, as to type, to whom payable, when due, and to what property, it any, a tax lien attaches).
Section 7. Other Liabilities. (Describe in detail. Use attachments if necessary. Each attachment must be identified as a part of this statement and
signed)..
Section 8. Life Insurance held. (Give face amount and cash surrender value of policies – name of insurance company and beneficiaries).
I authorize the New York State Department of Transportation to verify the accuracy of the statements made in order to determine whether I meet
the standards of economic disadvantage for participation in the New York State Department of Transportation Disadvantaged Business Enterprise
Program.
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Print Name: ___________________________________________ Social Security Number: ________________________________
Signature: _____________________________________________ Date: __________________________________
Title: _____________________________ ____________________
I swear that the foregoing statements and attachments are true and a ccurate. I understand that any misrepresentation in the Statement of Personal
Net Worth will be grounds for ter minating DBE certification status w ith the New York State Department of Transportation. I fu rther understand
that any misrepresentation made in this Statement of Personal Net Worth is subject to both the civil and criminal laws of the State of New York
and may also be referred to the Department of Justice for criminal prosecution under 18 U.S.C. 1001, which prohibits false statements in Federal
programs.
SWORN BEFORE ME
This__________ day of ______ 20 _____ Signature: _____________________________ ___
Name: ___________________________________
______________________ ____________
Signature of Notary Public Date: ____________________________________
