Personal Financial Statement — Short Form

One-page balance sheet for repeat sponsors and small-balance requests. Use the long form (818-PFS) for new relationships or facilities > $2M.

As-of date

Reporting basis

Individual — assets owned solely by me; joint ownership identified.

Joint — includes spouse / co-borrower; reflects proportionate interest.

01 Borrower / Co-Borrower

Borrower name

Co-borrower name

Date of birth

Social security no.

Home / mobile phone

Occupation / employer

Mailing address

02 Balance Sheet

Assets ($)
Cash & equivalents
Marketable securities
Retirement (IRA / 401(k))
Real estate (per SREO)
Personal property & vehicles
Other assets
Total assets

Liabilities ($)
Credit cards & revolving
Auto / installment loans
Real estate mortgages
Notes payable to others
Unpaid taxes
Other liabilities
Total liabilities

Net Worth
Annual gross income (combined)

03 Contingent Debt Debt on which I act as guarantor or co-signer. No contingent debt — certify by checking

#	Lender / creditor	Business / entity name	Individual guarantor	% guar	Balance	Mo. pmt	Rate

04 Disclosure

Have you ever declared bankruptcy?

YesNo

Are you involved in any pending legal actions, claims, or judgments?

YesNo

Are you obligated to pay alimony, child support, or separate maintenance?

YesNo

05 Certification

The information in this statement is provided for the purpose of obtaining or maintaining credit with 818 Capital Partners on behalf of the undersigned, or on behalf of others for which the undersigned may be severally or jointly obligated, or who execute a guaranty or provide collateral. The undersigned certifies that the information provided is true, accurate, and complete, and that 818 may consider this statement as continuing to be true and correct until written notice of change is delivered. 818 is authorized to obtain credit reports and make all inquiries it deems necessary to verify the accuracy of the statements made herein and to determine creditworthiness.

Signature of borrower

Date

Signature of co-borrower

Date

818 Capital Partners · 110 Wall Street, New York, NY 10005 One page · Form 818-PFS-S