Personal Financial Statement

OUR

Our Application for Franchise Consideration consists of a Personal Questionnaire and a Financial Statement.
If you are considering a partnership, each partner will need to complete the Application for Franchise Consideration.
You will receive a copy of the completed application in a PDF format after you click the “Submit” button.
We will review your application and schedule a call with you to go over it together and discuss financing options if needed and next steps.
Thank you for your continued interest in Apricot Lane Boutique!

COUNTRY VISIONS INC.

Personal Financial Statement
Name
Spouse if applicable
Marital Status
- Single
- Married
- Divorced
- Widowed
Address
Street Address City State ZIP Code
Phone
Email*
Section 1. Cash on Hand & in Banks (Checking & Savings)
Bank Name
Checking or Savings
Current Balance
Bank Name
Checking or Savings
Current Balance
Bank Name
Checking or Savings
Current Balance
Bank Name
Checking or Savings
Current Balance
Total Cash On Hand
Section 2. Stocks & Bonds (Combined)
Name of Securities
Market Value
Name of Securities
Market Value
Name of Securities
Market Value
Name of Securities
Market Value
Total Market Value
Section 3. Real Estate
Street Address
City & State
Original Purchase Price
Current Market Value
Current Outstanding Mortgage
Type (Single Family, Townhouse, Condo, Multi-Family, Land, Business, Commercial)
% of Ownership
Street Address
City & State
Original Purchase Price
Current Market Value
Current Outstanding Mortgage
Type (Single Family, Townhouse, Condo, Multi-Family, Land, Business, Commercial)
% of Ownership
Street Address
City & State
Original Purchase Price
Current Market Value
Current Outstanding Mortgage
Type (Single Family, Townhouse, Condo, Multi-Family, Land, Business, Commercial)
% of Ownership
Street Address
City & State
Original Purchase Price
Current Market Value
Current Outstanding Mortgage
Type (Single Family, Townhouse, Condo, Multi-Family, Land, Business, Commercial)
% of Ownership
Street Address
City & State
Original Purchase Price
Current Market Value
Current Outstanding Mortgage
Type (Single Family, Townhouse, Condo, Multi-Family, Land, Business, Commercial)
% of Ownership
Total Current Market Value
Total Current Outstanding Mortgage
Section 4. Notes Payable to Banks & Others
Name of Noteholder(s)
Current Balance, Payment Amount, Expiration
Collateral if Applicable
Name of Noteholder(s)
Current Balance, Payment Amount, Expiration
Collateral if Applicable
Name of Noteholder(s)
Current Balance, Payment Amount, Expiration
Collateral if Applicable
Name of Noteholder(s)
Current Balance, Payment Amount, Expiration
Collateral if Applicable
Name of Noteholder(s)
Current Balance, Payment Amount, Expiration
Collateral if Applicable
Total Notes Payable to Banks & Others
Assets
Cash on Hand & in Banks (Checking and Savings. Describe in Section 1)
Money Market & Cert. of Deposits
IRA or Other Retirement Account
Total Accounts Receivable
Life Insurance (Cash Surrender Value Only)
Stocks & Bonds (Describe in Section 2)
Real Estate (Describe in Section 3)
Business Value
Automobiles (Present Value)
Other Personal Property
Other Assets
Total Assets
Liabilities
Mortgages on Real Estate (Describe in Section 3)
Notes Payable to Banks & Others (Describe in Section 4)
Outstanding Total Credit Card(s)
Other Liabilities
Total Liabilities
Net Worth
Source of Income
Net Annual Salary
Net Investment Income
Net Real Estate Income
Net Other Income (Describe below)
Total Net Income
Credit Release
I hereby give my full consent to Country Visions, Inc, its agents, sub-agents or associates to request and obtain information, on my business and myself with regard to my personal and/or business credit history, both present and past history and any information relating to same. This is to be used for the purpose of establishing my current and past position and financial creditability. This is for the use and review only by Country Visions staff and those owner(s) and representatives of the commercial property I am interested in leasing.
Signature*
Printed Name*
Date*
Date Format: MM slash DD slash YYYY
Social Security Number
Signature (Spouse)
Printed Name (Spouse)
Date
Date Format: MM slash DD slash YYYY
Social Security Number (Spouse)
Source

Personal Financial Statement

COUNTRY VISIONS INC.

Personal Financial Statement

Section 1. Cash on Hand & in Banks (Checking & Savings)

Section 2. Stocks & Bonds (Combined)

Section 3. Real Estate

Section 4. Notes Payable to Banks & Others

Assets

Liabilities

Source of Income

Credit Release