QEF Personal Net Worth Statement

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Required for proprietorships or in support of small business applications

Personal Information

First Name. Last Name

Address.....
City ...........Prov PC

Home Ph..... E-Mail

Soc Ins Number Date of birth (mm/dd/yy)(required for credit investigation)

Employment Information

(if business is not full time)

Employer... For Yrs Mos Wage/Salary

If employed at above less then 2 years then list previous Employer.

Employer... For Yrs Mos Wage/Salary

Full Time Self Employed?

Trade style

Last Tax Return Gross Income Net Income

Soft  Expense Explain

(Note providing a copy of return will be a condition of approval)

Assets

Cash in bank.......
Notes Receivable.
Stocks & Bonds ..Life Insurance Cash Value ( do not enter the death value!)
Real Estate fmv ..Year bought Orig Cost
2nd ppty..............Year BoughtOrig Cost
Other Assets ......Describe
-------------------- ..Describe
--------------------.. Describe
-------------------- ..Describe

Liabilities

Bank Loans.....Monthly Payment ......................
Other Loans....Monthly Payment or when due
Taxes ............
RE Mortgage. Monthly Payment......................(excl taxes)
RE Mortgage..Monthly Payment......................
Credit Cards...Total Monthly min Payment.....

List Cards Carried

I/We acknowledge that by submitting this Personal Application Net Worth Statement to QEF Consulting Services ("QEF") applicant authorizes QEF or its assign to make enquiries into the Applicant's credit background and to use the information obtained to reach a credit decision. Applicant also authorizes all references herein described and credit reporting agencies to release such information to QEF or its assign.

Authorized by Name

Or