As of ____________________, 19



Denver International Airport

Personal Financial Statement

Complete this form for (1) each proprietor, or (2) each limited partner who owns 20% or more interest and each general partner, or (3) each stockholder owning 20% or more of voting stock, or (4) any person or entity providing a guaranty on the Agreement.

|Name: |Business Name: |

|Social Security Number: Date of Birth: |Tax ID #: |

|Residence Address: |Business Address: |

|Residence Phone: ( ) |Business Phone: ( ) |

|Nearest relative or contact: | |

|Name: |Home Phone: ( ) |

|Address: | |

|ASSETS |LIABILITIES |

|Cash |$ |Short Term Notes Due Financial Institutions |$ |

|(Schedule 1) | |(Schedule 7) | |

|Securities | |Short Term Notes Due Others | |

|(Schedule 2) | |(Schedule 7) | |

|Life Insurance Cash Value | |Credit Accounts and Bills Due | |

|(Schedule 3) | |(Schedule 8) | |

|Mortgages & Contracts Held By You | |Insurance Loans | |

|(Schedule 4) | |(Schedule 3) | |

|Homestead | |Installment Loans & Contracts | |

|(Schedule 5) | |(Schedule 7) | |

|Other Real Estate | |Mortgages on Home | |

|(Schedule 5) | |(Schedule 5) | |

|Profit Sharing & Pension | |Mortgages on Other Real Estate | |

|( Schedule 6) | |(Schedule 5) | |

|Retirement Accounts, Include IRA Accounts | |Taxes | |

|(Schedule 1) | | | |

|Automobiles (Describe) | |Other Liabilities (Describe) | |

|Personal Property | | | |

|Other Assets (Describe) | | | |

|TOTAL $ | |TOTAL $ | |

| | |NET WORTH $ | |

| | |(Total Assets Less Total Liabilities) | |

|ANNUAL INCOME | |Please answer each question (Yes or No) | |

|Salary | |Are you a Co-Maker, Endorser, or Guarantor of any other | |

| | |person’s debt? | |

|Bonuses/Commissions | |Are you a defendant in any suit or legal action? | |

|Dividends/Interest | |Have you ever gone through bankruptcy or had a judgment against| |

| | |you? | |

|Net Real Estate Income | |Have you ever been convicted of a felony and/or found guilty of| |

| | |any law violations other than parking tickets or juvenile | |

| | |offenses? | |

|Income from alimony, child support, or maintenance | |Have you ever defaulted on any government | |

|payments need not be entered unless you want it | |loan? | |

|considered as a basis for repayment. | | | |

|Other (Describe) | |Do you have any unpaid tax obligations? | |

|TOTAL $ | |Are you a U.S. citizen or a permanent resident of the U.S.? | |

| | | |

|SCHEDULE 1 | | |

|Cash, Savings, Certificates and IRA Accounts | | |

|Name of Bank or Financial Institution |Type of Account |Account Balance |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| |TOTAL $ | |

|SCHEDULE 2 | | |

|Securities Owned | | |

|Par Value or |Description |Registered in |Listed or Unlisted |Current Market |

|Number of Shares | |Name(s) of | |Value |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | |TOTAL $ | |

|SCHEDULE 3 |

|Life Insurance |

|Insurance Company |Insured |Beneficiary |Face Value of |Cash Value of Policy |Loans |

| | | |Policy | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | |TOTAL $ | | |

|SCHEDULE 4 |

|Receivables due to me on mortgages and contracts |

|Name of Debtor |Description of Property |First lien or |Date of Maturity |Repayment Terms |Balance Due |

| | |Second lien | | | |

| | | | | | |

| | | | |Per | |

| | | | | | |

| | | | |Per | |

| | | | | | |

| | | | |Per | |

| | | | | | |

| | | | |Per | |

| | | | |TOTAL $ | |

|SCHEDULE 5 |

|Real Estate Owned |

|Property Description |Name of Creditor |Year |Purchase Price |Mortgage Balance |Date of |Repayment Terms |Current Market |

| | |Acq. | | |Maturity | |Value |

| | | | | | | | |

| | | | | | |Per | |

| | | | | | | | |

| | | | | | |Per | |

| | | | | | | | |

| | | | | | |Per | |

| | | | | | | | |

| | | | | | |Per | |

| | | | | | | | |

| | | | | | |Per | |

| | | | | | |TOTAL $ | |

|SCHEDULE 6 |

|Profit Sharing and Pension |

|Name of Institution |Type of Account |Account Balance |Amount Totally Vested |Loans |

| | | | | |

| | | | | |

| |TOTAL $ | | | |

|SCHEDULE 7 | | | | |

|Installments, Credit Lines and Notes | | | | |

|Name of Creditor |Collateral |Date of Maturity |Repayment Terms |Balance Due |

| | | | | |

| | | |Per | |

| | | | | |

| | | |Per | |

| | | | | |

| | | |TOTAL $ | |

|SCHEDULE 8 |

|Credit Accounts, Bills Due, Alimony/Child Support, Daycare, etc. |

|Name of Company |Repayment Terms |Balance Due |

| | | |

| |Per | |

| | | |

| |Per | |

| | | |

| |Per | |

| | | |

| |TOTAL $ | |

You certify that the information in this statement is true and correct. Denver International Airport is authorized to retain this personal financial statement whether or not an Agreement is approved and is further authorized to verify your credit and employment history or any other information in this statement. This application does not obligate Denver International Airport in determining whether to approve or deny an Agreement.

Applicant’s Signature: ________________________________ Date: _______________

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