PERSONAL STATEMENT OF FINANCIAL AFFAIRS
All shareholders, partners and personal guarantors must complete and
attach a Personal Statement of Financial Affairs to the Application form*
General Information
First Name:
Middle Initial:
Surname:
Birth Date:
Home Mailing Address:
Community:
Postal Code:
Home Phone #:
Email:
Your Employer:
Position:
Work Phone #:
Your Annual Income:
Marital Status:
Spouse’s First Name:
Spouse’s Surname:
Spouse’s Annual Income:
*If you are married or common law then please complete the net worth statement
together combining all of the assets and liabilities for both spouses.
Total Family Income:
PERSONAL NET WORTH STATEMENT
List all Assets
List all Debts & Liabilities
Cash & Bank Accounts:
$
Mortgage - First:
$
Term Deposits/G.I.C. etc.:
$
Mortgage - Second:
$
Stocks/Bonds/Mutual Funds**:
$
Bank Lines of Credit:
$
R.R.S.P.s / Pensions:
$
Overdraft Balance:
$
Real Estate – Personal use:
$
Bank Loans:
$
Real Estate – Investment:
$
Credit Cards:
$
Automobiles:
$
Private Loans:
$
Recreational Vehicles:
$
Cosigned/Guaranteed debt:
$
Other (specify):
$
Other (specify):
$
Other (specify):
$
Other (specify):
$
Other (specify):
$
Other (specify):
$
Other (specify):
$
Other (specify):
$
Other (specify):
$
Total Liabilities:
$
Other (specify):
$
Net Worth (Assets – Liabilities):
$
Total Assets
$
Total Liabilities & Net Worth
$
AssAssets:
** Do not include the value of the business that is applying.
Page 1/2
NWT Business Development and Investment Corporation
(01/16)
Real Estate Details
Property Address
Registered Owner(s)
Mortgage
Market Value Balance
Equity
Credit Limit
Security
Debt & Liability Details (other than the mortgages included above)
Description
Lender/Creditor
Balance
GENERAL INFORMATION
1. Have you ever had an asset repossessed by a creditor? YES ( ) NO ( ) If yes, explain.
2. Are you involved in any lawsuits or claims that could affect your financial situation? YES ( ) NO ( ) If yes,
Explain.
3. Have you ever declared bankruptcy? YES ( ) NO ( ) If yes, when?
Are you discharged? YES ( ) NO ( ) If no, why?
4. Do you have any outstanding liabilities to the Government of the Northwest Territories, Canada Revenue
Agency or the Workers Safety and Compensation Commission? YES ( ) NO ( ) If yes, please provide details.
5. Are you a shareholder, director or stakeholder of any other business, corporation, partnership, proprietorship,
etc.? YES ( ) NO ( ) If yes, provide details (i.e. name of business, nature of your involvement and amount
and nature of your interest).
APPLICATION DECLARATION
I the undersigned hereby declares that all information provided herein is true, complete and correct, to the best of
my knowledge. I understand that the information contained herein may be used by the NWT Business
Development & Investment Corporation (“BDIC”) to determine program eligibility. I further consent to the BDIC
making any credit and general inquiries necessary in relation to this application and to the disclosure of
any credit information about me, to any credit reporting agency, organization or person with whom I have
a financial relationship. This is to include the GNWT Department of Finance.
Signature:
Page 2/2
Date:
NWT Business Development and Investment Corporation
(01/16)