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1 Local Small Business Opportunity Program Disadvantaged Business Enterprise Augusta-Richmond County 501 Greene Street, Suite 304 Augusta, Georgia 30901 Personal Financial Statement As of 200__ (These statements are not subject to public disclosure) Complete this for: each proprietor, or each limited partner or general partner, or each stockholder. Name: Business Phone: Residence Address: Residence Phone: City, State and Zip Code: Business Name of Applicant: ASSETS (Omit Cents) LIABILITIES (Omit Cents) Cash on hand & in Savings IRA or Other Retirement Accounts & Notes Life Insurance – Cash Surrender Value Stocks and Real Automobile-Present Other Personal Ownership in Other Business…………………………… Total Accounts Notes Payable to Banks and Installment Account Payments Installment Account Payments Loan on Life Insurance……………………….. Mortgages on Real Unpaid Other Liabilities………………………………. Total Net Worth (Total Assets Minus Total Liabilities)…………………………………… I hereby certify that no assets have been transferred to any beneficiary for less than fair market value in the last two years. I authorize the Augusta-Richmond County Disadvantaged Business Enterprise Department to verify the accuracy of the statements made in order to determine whether I meet the standards for participation in the Local Small Business Opportunity Program. These statements are true and correct to the best of my belief. Signature: Date: Social Security 3/9/08