Personal Financial Statement

Please complete all sections of this statement. Spaces left unfilled will be assumed to mean “no” or “None”. You may attach additional sheets and supporting documents.

Shopping Center / Leasing Information

Shopping Center Name

Leasing Representative

Section A: Business Information

Please attach the last 2 years and Year-to-Date Profit and Loss Statement and Balance Sheet along with Articles of Incorporation if applicable.

Business Name (DBA)

Legal Entity

Federal Tax ID

State of Formation

Form of Business

Date Business Began

Present Location of Business

City

State

Zip

Business Number

Number of Years at This Location

Lease Written Under (Name)

Landlord or Mortgage Holder

Landlord or Mortgage Holder Phone Number

Estimated Annual Lease Obligation

Applicant Information

Applicant Name

Email Address

Address

City

State

Zip

Home Phone Number

SSN

Date of Birth

Fax Number

State Issued & Driver License #

Cell Number

Business Number

Number of Years at This Location

Name of Employer

Employer Address

Employer City

Employer State

Employer Zip

Work Number

Position or Title

Years Employed

Spouse Information

Applicant Name

Email Address

Address

City

State

Zip

Home Phone Number

SSN

Date of Birth

Fax Number

State Issued & Driver License #

Cell Number

Business Number

Number of Years at This Location

Name of Employer

Employer Address

Employer City

Employer State

Employer Zip

Work Number

Position or Title

Years Employed

Section C: Balance Sheet, Supporting Schedules and Income Statement

Please list only the portion of assets and liabilities that belong to you.

Assets	Amount	Liabilities & Net Worth	Amount
Cash on hand & in Banks		Accounts Payable
Savings Accounts		Notes Payable to Banks and Others (Schedule 2)
IRA or Other Retirement Account		Installment Accounts (Auto)
Cash Value of Life Insurance (Schedule 8)		Installment Accounts (Other)
Stocks and bonds (Schedule 3)		Loan on Life Insurance
Real Estate (Schedule 4)		Mortgages on Real Estate (Section 4)
Automobile - Present Value		Unpaid Taxes (Section 6)
Other Personal Property (Schedule 5)		Other Liabilities (Section 7)
Other Assets (Schedule 5)

Section 1: Sources of Income & Contingent Liabilities

Salary

Net Investment Income

Real Estate Income

Other Income (Describe)

As Endorser or Co-Maker

Legal Claims & Judgments

Other Special Debt

Description of Other Income

Section 2: Notes Payable to Banks and Others

Name and Address of Noteholder(s)	Original Balance	Current Balance	Payment Amount	Frequency	Collateral

Section 3: Stocks and Bonds

Name of Securities

Number of Shares

Cost

Market Value

Quotation / Exchange

Date of Quotation / Exchange

Total Value

Section 4: Real Estate

Please list each parcel separately.

Property A

Type of Property

Address

Date of Purchase

Original Cost

Present Market Value

Name & Address of Mortgage Holder

Mortgage Account Number

Amount of Payment per Month/Year

Status of Mortgage

Property B

Type of Property

Address

Date of Purchase

Original Cost

Present Market Value

Name & Address of Mortgage Holder

Mortgage Account Number

Amount of Payment per Month/Year

Status of Mortgage

Property C

Type of Property

Address

Date of Purchase

Original Cost

Present Market Value

Name & Address of Mortgage Holder

Mortgage Account Number

Amount of Payment per Month/Year

Status of Mortgage

Sections 5–7

Section 5: Other Personal Property and Other AssetsSection 6: Unpaid TaxesSection 7: Other Liabilities

Attach Documents

Accepted: PDF, JPG, PNG. Maximum 10 MB per file.

Drivers License

Profit & Loss Statement / Balance Sheet

Bank Statements & Tax Returns

Miscellaneous Files

Terms & Conditions

I (we) authorize NorthStar Investment Group and/or its agents to make inquiries and pull credit report(s) as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify the above and the statements contained in the attachments are true and accurate as of the stated date(s). The statements are made for the purpose of either entering into a Lease Agreement or guaranteeing a Lease Agreement. I understand that FALSE statements may result in forfeiture of benefits and possible prosecution. The exchange of digital images of this Personal Financial Statement, as executed, shall constitute good and sufficient delivery for all purposes under applicable law and such digital images may be utilized for the purpose of this Personal Financial Statement.

I agree to the above Terms and Conditions.

Digital Signatures

Applicant Name

Applicant Title

Spouse Name

Spouse Title

Personal Financial Statement

Shopping Center / Leasing Information

Section A: Business Information

Applicant Information

Spouse Information

Questions

Section C: Balance Sheet, Supporting Schedules and Income Statement

Section 1: Sources of Income & Contingent Liabilities

Section 2: Notes Payable to Banks and Others

Section 3: Stocks and Bonds

Section 4: Real Estate

Property A

Property B

Property C

Sections 5–7

Attach Documents

Terms & Conditions

Digital Signatures

Applicant Signature

Spouse Signature