SELF-EMPLOYED VERIFICATION REPORT – CONFIDENTIAL -

.BORROWER’S NAME

LAST NAME FIRST NAME MIDDLE NAME

REGISTERED OWNER OF BUSINESS
BUSINESS NAME

NATURE OF BUSINESS
BUSINESS ADDRESS
BUSINESS CONTACT NO.

BUSINESS OWNERSHIP SOLE PROPRIETORSHIP PARTNERSHIP CORPORATION

TYPE OF BUSINESS MERCHANDISE-BASED SERVICE-BASED

YEARS IN BUSINESS: TRADE CHECKING CLIENT CHECKING SUPPLIER CHECKING

BUSINESS AREA STATUS (RESIDENTIAL / COMMERCIAL / RURAL) BUSINESS NAME:

NO. OF PERSONNEL: CONTACT NO.

DAILY SALES / REVENUE: GOODS RENDERED:

MONTHLY SALES / REVENUE REPAYMENT:

MARK UP: AMOUNT PER TRANS:

OPERATING EXPENSE: NO. OF YEARS / PERFORMANCE

MONTHLY NET INCOME / REVENUE: LAST TRANSACTION DATE:

REMARKS: INFORMANT / POSITION:

OTHER INCOME INFO: WITH PROOF OF OTHER INCOME WITHOUT PROOF OF OTHER INCOME

NET INCOME EXPENSES NDI COMPUTATION

BORROWER’S INCOME: LIVING EXPENSES TOTAL NET INCOME:

OTHER INCOME: OTHER EXPENSES TOTAL EXPENSES:

CO-MAKER INCOME MONTHLY AMORT. DBR: NDI:

TOTAL NET INCOME: TOTAL EXPENSES: NOTE: COMPUTATION OF NDI = TOTAL GROSS
INCOME / TOTAL EXPENSES

PREPARED BY:

NAME OF CREDIT INVESTIGATOR SIGNATURE DATE PREPARED