Buyer Profile and Personal Financial Statement.

Buyer Profile and Bid Detail

How many sites are your bidding on?

List the site numbers & addresses for each site

Name of Person/Entity Acquiring the Location

Entity Tax ID Number

Entity Address

Street Address Address Line 2 City State ZIP Code

Current Business Backgrounder

Please provide written background on your current business and business assets, including number of retail locations currently owned, currently operated, geographical locations, and other relevant information to be considered with your proposal.

Buyer(s)

Name

Spouse's Name

Business Phone

Home / Cell Phone

Home Address

Street Address City State ZIP Code

Business Name

Business Type

The provided information is current as of

Assets

Cash on Hand & in banks

Savings Accounts

IRA or Other Retirement Account (Describe in Section 5)

Accounts & Notes Receivable (Describe in Section 5)

Life Insurance – Cash Surrender Value Only…… (Describe in Section 8)

Stocks and Bonds (Describe in Section 3)

Real Estate (Describe in Section 4)

Automobiles (Describe in Section 5, and include Year/Make/Model)

Other Assets (Describe in Section 5)

Other Personal Property (Describe in Section 5)

Total Assets

Liabilities

Accounts Payable

Notes Payable to Banks and Others (Describe in Section 2)

Installment Account (Auto)

Auto Monthly Payment

Installment Account (Other)

Other Monthly Payment

Notes Payable to Banks and Others (Describe in Section 2)

Mortgages on Real Estate (Describe in Section 4)

Unpaid Taxes (Describe in Section 6)

Other Liabilities (Describe in Section 7)

Total Liabilities

Net Worth

Contingent Liabilities

As Endorser or Co-Maker

Legal Claims & Judgements

Provision for Federal Income Tax

Other Special Debt

Source of Income

Salary

Net Investment Income

Real Estate Income

Other Income (Describe below)

Other Income Detail

Description of Other Income included above. (Alimony or child support payments should not be disclosed in “Other Income” unless it is desired to have such payments counted toward total income)

Notes Payable to Banks and Others.

Stocks and Bonds

Real Estate Owned

Property 1 Type

Type of Real Estate (e.g. Primary Residence, Other Residence, Rental Property, Land, etc.)

Property 1 Address

Street Address City State ZIP Code

Property 1 Date Purchased

Property 1 Original Cost

Property 1 Current Market Value

Property 1 Mortgage Holder

Property 1 Mortgage Account Number

Property 1 Mortgage Balance

Property 1 Mortgage Holder Address

Street Address City State ZIP Code

Property 2 Type

Type of Real Estate (e.g. Primary Residence, Other Residence, Rental Property, Land, etc.)

Property 2 Address

Street Address City State ZIP Code

Property 2 Date Purchased

Property 2 Original Cost

Property 2 Current Market Value

Property 2 Mortgage Holder

Property 2 Mortgage Account Number

Property 2 Mortgage Balance

Property 2 Mortgage Holder Address

Street Address City State ZIP Code

Property 3 Type

Type of Real Estate (e.g. Primary Residence, Other Residence, Rental Property, Land, etc.)

Property 3 Address

Street Address City State ZIP Code

Property 3 Date Purchased

Property 3 Original Cost

Property 3 Current Market Value

Property 3 Mortgage Holder

Property 3 Mortgage Account Number

Property 3 Mortgage Balance

Property 3 Mortgage Holder Address

Street Address City State ZIP Code

Additional Real Estate Owned

List each parcel separately and include information asked for properties 1-3.

Other Personal Property and Other Assets

Describe, and, if any is pledged as security, state name and address of lien holder, amount of lien, terms of payment and, if delinquent, describe delinquency.

Unpaid Taxes

Describe in detail as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.

Other Liabilities

Describe in detail.

Life Insurance Held

Give face amount and cash surrender value of policies – name of insurance company and Beneficiaries.

Loan(s) Against Life Insurance

Certifications and Signatures

I authorize CORNER REALTY, LLC AND ITS CLIENT FOR THIS PROJECT to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness.

CERTIFICATION: (to be completed by each person submitting the information requested on this form and the spouse of any 20% or more owner when spousal assets are included)

By signing this form, I certify under penalty of criminal prosecution that all information on this form and any additional supporting information submitted with this form is true and complete to the best of my knowledge. I understand that CORNER REALTY LLC OR ITS CLIENT will rely on this information when making decisions regarding applicant’s creditworthiness to acquire the Business and/or Property for its proposal associated with this application I further certify that I have read the attached statements required by law and executive order.

Signature

Social Security Number

Name

Date

Signature 2

Social Security Number 2

Name 2

Date

Email

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