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Personal financial statement S

Section 1 – Personal Information

First Name Middle Initial Last Name

Date of Birth (yyyy-mm-dd) Social Insurance Number Primary Phone Number Business Phone Number

Marital Status
Single Married Divorced/Separated

Current Address
Apt / Unit Number Street Address

City / Town Province Postal Code

Time at Address Residence Status

Years Months Owner Renter Other

Previous Address if current less than 2 years

Apt / Unit Number Street Address

City / Town Province Postal Code

Employer Information
Current Employer Current Position / Title Length of Employment
Years Months
Previous Employer if less than 2 years Current Position / Title Length of Employment
Years Months

Section 2 – Co-Applicant Information if applicable

First Name Middle Initial Last Name

Date of Birth (yyyy-mm-dd) Social Insurance Number Primary Phone Number Business Phone Number

Employer Information
Current Employer Current Position / Title Length of Employment
Years Months
Previous Employer if less than 2 years Current Position / Title Length of Employment
Years Months

Form_1556 (2018-01-05) Page 1 of 3

 Section 3 – Personal Net Worth Statement
Assets Liabilities
Current
Asset Type Institution Liability Type Current Outstanding
Value

Cheq/savings Credit card(s)

accounts

Term deposits/GIC’s

Stocks/bonds/mutual
funds

RRSP’s (savings, RRSP loan(s)

terms, stocks, bonds)

Automobile
(year/make)

Other assets (provide Auto loan(s)/lease(s)

brief description)

Line of credit(s) Balance owing Authorized limit

Personal loan(s) and

other liabilities

Canadian Real Estate (refer to section 5) Mortgage(s) on

Canadian real estate
(refer to section 5)
Total assets $ Total Liabilities $

Section 4 - Monthly Income and Expenses

Income Expenses
Your Income Gross Monthly Amount Your Monthly Expenses Monthly Payment Amount

Salary or wages $ Mortgage/rent $

$ Strata/maintenance $

$ Property taxes $

Co-applicant’s Income (if applicable) $

Monthly salary or wages $ $

$ $

$ $

Form_1556 (2018-01-05) Page 2 of 3

 Section 5 - Canadian Owned Real Estate Details
If attachments being provided with information please note connection to this statement and sign
Property A Property B Property C
Property Type (eg. residential,
commercial, raw land)
Address

Registered owner(s)

Percent Ownership

Mortgage Holder (bank) &

Account No.
Present Market Value

Mortgage Balance
Outstanding
Mortgage Payment Per Month

Monthly Rental Income

Section 6 – Insurance Coverage

Applicant Co-Applicant
Benefit Benefit
Life $ Life $
Critical Illness $ Critical Illness $
Disability $ / month Disability $ / month
Loss of Employment $ / month Loss of Employment $ / month

Section 7 - Personal Declarations

Have you ever experienced a repossession? Yes No
Have you ever declared bankruptcy? Yes No If Yes, when? ____________________
Are you a party to any claims or suits? Yes No
Do you owe any income tax for years prior Yes No If Yes, outstanding amount $ _____________
to the current year?
Signature(s)

I/We hereby certify the information I/we have provided is true, correct and complete; I/We acknowledge to have
received a copy of the Privacy Statement and agree to be bound thereby; I/we authorize Vancity to obtain an
information report on me/us (or our co-applicant) from a consumer reporting agency, or to give information
about me/us to, or receive such information from, any credit reporting agency or other financial institution.
Authorized Signature Name

X .……………………………………………..
Date Signed (yyyy-mm-dd)

Authorized Signature Name

X .……………………………………………..
Date Signed (yyyy-mm-dd)

Form_1556 (2018-01-05) Page 3 of 3