Atlantic Home Warranty - PERSONAL NET WORTH STATEMENT

PERSONAL NET WORTH STATEMENT

Not for use by Corporations. Include Personal Assets and Debits only.

Name of Principal

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ASSETS

Cash and Bank Deposits: $

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Cash Surrender value of life insurance: $

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Investments, Stocks, Bonds at market value: $

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Land and buildings at costs:

Location 1

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Registered Owner 1

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$

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Location 2

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Registered Owner 2

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$

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Inventory (at cost): $

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Account Receivable: $

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Vehicles and Equipment at cost less depreciation: $

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Other Assets, in detail (at cost):

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Total Assets: $

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LIABILITIES

LOANS Payable: $

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Mortgages on Real Estate: $

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Accounts Payable: $

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Credit Card Balances: $

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Other Payables (specify): $

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Total Liabilities:$

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Have you guaranteed any obligations not included in our liabilities shown above? (If so, give name and amounts)

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Are there any judgements against you?

Yes

No

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Have you ever failed in business?

Yes

No

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Are you threatened with any lawsuits?

Yes

No

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If yes to any of these questions provide details

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TO BE SWORN BEFORE A COMMISSIONER OF OATHS, NOTARY PUBLIC, SOLICITOR OR PERSON LEGALLY AUTHORIZED TO ADMINISTER AN OATH.

I/We the undersigned swear that the information set out above contains no material misrepresentations or omissions which would adversely affect the acceptance of this document, when making “Application for Registration” with Atlantic Home Warranty (AHW).

SWORN to before me at

Location

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in the Province of

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day of

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Name :

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Applicant :

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Title:

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Spouse:

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Signature:

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I/we agree that all the information provided on this form may be used and disclosed by the Program for the purpose of assessing this application to become a member of AHW, and for re-assessing such membership from time to time. AHW will provide a copy of its Privacy Policy upon request.

PERSONAL NET WORTH STATEMENT

ASSETS

LIABILITIES

TO BE SWORN BEFORE A COMMISSIONER OF OATHS, NOTARY PUBLIC, SOLICITOR OR PERSON LEGALLY AUTHORIZED TO ADMINISTER AN OATH.

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