Personal Net Worth Statement

For Commercial Real Estate Mortgages, Business Acquisitions & Large Institutional Facilities ($500K–$25M+). Looking for a fast Merchant Loan or Working Capital ($5K–$500K)? Apply & upload bank statements in 60 seconds here.

60-Sec Fast Application

1. Personal Information Applicant & Guarantor Identification

First Name (Please Print) *

Last Name *

Date of Birth (MM/DD/YYYY) *

SIN Number (Optional)

Driver’s License

Corporate or Personal Email Address *

Telephone (Home / Mobile) *

Telephone (Work)

Current Address *

Length of Time at Current Address

Marital Status

Spouse’s Name (If Applicable)

Number of Dependents

2. Employment Information Income & Banking References

Employer’s Name / Company

Present Position / Title

Length of Service

Employer’s Address

Annual Employment Income ($)

Details (Salary, Bonus, Dividends)

Income From Other Sources ($)

Specify Other Income Sources

Total Annual Income ($)

State Year of Reference

Bank Reference (Institution & Contact)

Bank Address / Branch

3. Summary – Financial Information Auto-Syncs With Schedules A, B, C & D Below

Assets	Description	Value ($)
Cash, Deposits & Marketable Securities
Investments (Specify)
Other Assets (Itemize)
Real Estate
Equity in Non-Arms Length Companies
Total Assets

Liabilities	Description	Balance Owing ($)
Outstanding Loans
Margin Accounts
Outstanding Mortgages
Other Liabilities (Itemize)
Guarantees or Other Obligations to Third Parties
Total Liabilities

4. Assets: Section “A” – Securities, Tax Shelters, Other Investments or Assets

Description of Security and Quantity Held	Registered To / To Whom Pledged	Market Value ($)	Cost ($)	Margin Accounts Balance Owing ($)	Annual Profit or Loss ($)





Schedule A Totals

Section “B” – Real Estate

Address and Description (Acreage, Home, Business)	Title in Name Of	Market Value ($)	Purchase Price ($)	Date Purchased	% Owned






Schedule B Totals

Section “C” – Equity in Non Arms-Length Companies

Name of Company	Nature of Business	Position / Relationship	Value of Equity Invested ($)	% of Ownership






Schedule C Total

Section “D” – Mortgages, Pledges of Security

Lender Name	Security / Collateral	Original Amount ($)	Outstanding Balance ($)	Terms & Rate






Schedule D Total

5. Declaration, Authorization & Signature Applicant Execution

BY SIGNING BELOW, I HEREBY:

I. CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS ACCURATE AND COMPLETE;
II. AUTHORIZE MIIBANC GROUP INC. AND ITS DESIGNATED INSTITUTIONAL LENDING PARTNERS (THE “LENDER”) TO COLLECT AND USE THE PERSONAL INFORMATION PROVIDED TO ASSESS A PERSONAL GUARANTEE OF THE LOAN OR GRANT FACILITY PROPOSED IN THE APPLICATION, INCLUDING OBTAINING MY CREDIT REPORT;
III. GRANT THE LENDER PERMISSION TO OBTAIN AND DISCLOSE THE PERSONAL INFORMATION DESCRIBED ABOVE WITH PROSPECTIVE SYNDICATE LENDERS AND INVESTORS IN THE LOAN FACILITY; AND
IV. AGREE THAT THIS COLLECTION, USE, DISCLOSURE AND EXCHANGE OF PERSONAL INFORMATION WILL CONTINUE UNTIL THE REVIEW OF THE BORROWER’S ELIGIBILITY IS COMPLETED, AND THE RESULTS WILL BE RETAINED IN ACCORDANCE WITH THE LENDER’S STANDARD DOCUMENT RETENTION POLICIES. I WARRANT AND CONFIRM THAT THE INFORMATION GIVEN HEREIN IS TRUE AND I UNDERSTAND CLEARLY THAT IT IS BEING USED TO DETERMINE MY ELIGIBILITY FOR CREDIT. YOU ARE AUTHORIZED TO OBTAIN ANY INFORMATION YOU REQUIRE RELATIVE TO THIS APPLICATION FROM ANY SOURCES TO WHICH YOU MAY APPLY AND EACH SUCH SOURCE IS HEREBY AUTHORIZED TO PROVIDE YOU WITH SUCH INFORMATION. YOU ARE FURTHERMORE AUTHORIZED TO DISCLOSE ANY RESPONSE TO DIRECT INQUIRIES FROM ANY OTHER LENDER OR CREDIT REPORTING AGENCY, SUCH INFORMATION ON MY LOANING ACCOUNT AS YOU CONSIDER APPROPRIATE, AND I HEREBY AGREE TO INDEMNIFY YOU AGAINST AND SAVE YOU HARMLESS FROM ANY AND ALL CLAIMS IN DAMAGES OR OTHERWISE ARISING FROM SUCH DISCLOSURE ON YOUR PART. YOU ARE ALSO AUTHORIZED TO RETAIN THE APPLICATION WHETHER OR NOT THE APPLICATION IS APPROVED.

Signature (Type Full Legal Name to Execute) *

Date (MM/DD/YYYY) *

Personal Net Worth Statement

1. Personal Information Applicant & Guarantor Identification

2. Employment Information Income & Banking References

3. Summary – Financial Information Auto-Syncs With Schedules A, B, C & D Below

4. Assets: Section “A” – Securities, Tax Shelters, Other Investments or Assets Add More

Section “B” – Real Estate Add More

Section “C” – Equity in Non Arms-Length Companies Add More

Section “D” – Mortgages, Pledges of Security Add More

5. Declaration, Authorization & Signature Applicant Execution

4. Assets: Section “A” – Securities, Tax Shelters, Other Investments or Assets

Section “B” – Real Estate

Section “C” – Equity in Non Arms-Length Companies

Section “D” – Mortgages, Pledges of Security