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Personal Net Worth Affidavit Local Small Business Opportunity Program (LSBOP) (These statements are not subject to public disclosure)1 Firm name: Please provide net worth information for each owner by completing the appropriate sections as requested below in order for this department to determine whether your firm is eligible for participation in the Local Small Business Opportunity Program (LSBOP). Personal Net Worth means the sum of the fair market value of the interests owned by an individual in all assets, minus the debt of the individual. If an asset is owned jointly as husband and wife, then fifty percent (50%) of the fair market value for that asset will be counted if only one spouse participates in the firm being reviewed. If debt is attributable to an asset owned jointly as husband and wife, then fifty percent (50%) of the debt will be counted if only one spouse participates in the firm being reviewed. Up to $500,000 of the equity or debt in the individual’s Primary Residence may be excluded when determining the Personal Net Worth as well as the individual’s ownership in the applicant firm. Section 1 Section 2 Section 3 Owner’s Name Ownership % Personal Net Worth AFFIDAVIT I swear that the foregoing statements are true and correct and include all the information necessary to determine the Personal Net Worth (PNW) of the firm’s owner(s). Further, I understand that the Disadvantaged Business Enterprise Department reserves the right to conduct investigations and request additional information necessary to verify the statements and information provided. Sworn to and subscribed before me this ____day of Executed by: (Name of Firm) Signature of Notary Public: Printed Name of My Commission expires on: Title: LSBOP – Registration Application 3/9/08 1The information submitted in this application is for the purpose of inducing registration approval by Augusta-Richmond County’s Local Small Business Opportunity Program. To the maximum extent permitted by the Georgia Open Records Act and other applicable law, Augusta-Richmond County seeks to protect the financial records of a business, including balance sheets and financial statements.