Form HUD-92417 Personal Financial and

U.S. Department of Housing and
Urban Development
Office of Housing
Federal Housing Commissioner

Personal Financial and
Credit Statement

OMB No. 2502-0001 (Exp. 09/30/2015)

Public reporting burden for this collection of information is estimated to average 8 hours per response, including the time for reviewing instructions
, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This information is required to obtain benefits. HUD may not
collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.
Section 207(b)(1) and (2) of the National Housing Act authorizes the Secretary of the Department of Housing and Urban Development to insure mortgages on property held by
Federal or State instrumentalities, municipal corporate instrumentalities of one or more States, or housing corporations restricted by Federal or State laws or regulations of State
banking or insurance departments as to rents, charges, capital structure, rate of return, or methods or operations; or to ensuree the property any mortgagor approved by the
Secretary. Assurances of confidentiality are pledged to respondents as stated in the Privacy Act. HUD may disclose this data on yl in response to a Freedom of Information
request.
Privacy Act Statement: HUD is authorized to collect this information by P. L. 479.48, Stat.1246, 12 USC 1701 et. seq.; and the Housing and Community
y Development Act of 1987,
42 USC 3543, to collect the Social Security Number (SSN). This report is authorized by law (24 CFR 207.1). It will be used as
, a minimum, to make a determination of the financial
and credit status of the respondent. HUD may disclose this information to Federal, State and local agencies when relevant civil, criminal, or regulatory investigations and prosecutions.
It will not be otherwise disclosed or released outside of HUD, except as required and permitted by law. Providing the SSN is mandatory. Failure to provide any of the information may
result in your disapproval of participation in this HUD program and/or delay action on your proposal.
Project Name:

Project Number:

Project Location:

Name & Address of Person(s) making this Statement:

Date Prepared :

Assets

Date of Statement:

Liabilities and Net Worth

Cash on hand in banks
Name of depository

Balance

Total

Accounts Payable

$

Notes Payable

$

$

Debts payable in less than one year
(secured by mortgages on land and buildings)

$

$

Debts payable in less than one year (secured by chattel
mortgages or other liens on assets)

$

Depository and Account No. - Restricted
Depository and Account No. - Unrestricted

Accounts Receivable

Other current liabilities: (describe)

$

Less: Doubtful Accounts

$

Notes Receivable

$

Less: Doubtful Notes

$

Stocks and Bonds - Market Value (Schedule A - reverse side) $
Other Current Assets:

(describe)

$
Total Current Assets

$

Real Property — at net * (Schedule B — reverse side)

$

Machinery Equipment and Fixtures — at net

$

Life Insurance (Cash value less loans)

$

Other Assets

$
Total Current Liabilities:

$

Debts payable in more than one year (secured by
mortgages on land and buildings)

$

Debts payable in more than one year (secured by chattel
mortgages or other liens on assets)

$

Other liabilities (describe)

(describe)

Total Assets

* Cost, including improvements, less depreciation.

$
Total Liabilities

$

$

Net Worth

$

$

Total Liabilities and Net Worth

$

Page 1 of 4

form HUD-92417 (05/2003)
ref. Handbook 4470.1

Accounts and Notes Receivable

Partner (P)

Employee (E)

Relative (R)

or other (O)*

Name (Indicate also P,E,R or O)*

Address

Maturity Date

Amount

Name (Indicate also P,E,R or O)*

Address

Maturity Date

Amount

Name (Indicate also P,E,R or O)*

Address

Maturity Date

Amount

Name (Indicate also P,E,R or O)*

Address

Maturity Date

Amount

Name (Indicate also P,E,R or O)*

Address

Maturity Date

Amount

Life Insurance

Face Value

Beneficiary

Type Liability

Amount

Circumstances

Type Liability

Amount

Circumstances

Type Liability

Amount

Circumstances

Type Liability

Amount

Circumstances

Type Liability

Amount

Circumstances

Delinquencies (starting with Federal Indebtedness)

Accounts and Notes Payable

Partner (P)

Employee (E)

Relative (R)

or other (O)*

Name (Indicate also P,E,R or O)*

Address

Amount

Maturity Date

Name (Indicate also P,E,R or O)*

Address

Amount

Maturity Date

Name (Indicate also P,E,R or O)*

Address

Amount

Maturity Date

Name (Indicate also P,E,R or O)*

Address

Amount

Maturity Date

Name (Indicate also P,E,R or O)*

Address

Amount

Maturity Date

Pledged Assets
Type Pledged

Amount

Offsetting Liability

Type Pledged

Amount

Offsetting Liability

Type Pledged

Amount

Offsetting Liability

Type Pledged

Amount

Offsetting Liability

Type Pledged

Amount

Offsetting Liability

Legal Proceedings: (If any legal proceedings have been instituted by creditors, or any unsatisfied judgments remain on record, give full details tsarting with any unresolved

Federal Indebtedness.)

Page 2 of 4

form HUD-92417 (05/2003)
ref. Handbook 4470.1

Schedule A — Stocks and Bonds (Note: If more space is required use a separate sheet of paper.)
Description

Number
of Shares

Current Market Value
(At date of this Statement)

If Listed, Name Exchange

Schedule B — Real Property (Indicate Private Residence, if any)
Location and Description of Land and Buildings Owned

Age

Original Cost

Market Value

Assessed Value

Mortgaged For

Insured For

Totals
Title (The legal and/or equitable title to all pieces of the above-described real estate is solely in my name, except as follows.)
Location of Real Property:

Name of Title Holders:

Page 3 of 4

form HUD-92417 (05/2003)
ref. Handbook 4470.1

Bank and/or Trade References
Name & Address:

Account Numbers:

Other Information/Remarks

I/We hereby certify that the foregoing figures and the statements contained here, submitted to obtain mortgage insurance under
the National Housing Act, are true and give
a correct showing of my/our financial condition as of this date.
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001,010,
1 1012; 31 U.S.C. 3729, 3802)
Name(s) & Signature(s):*

Social Security Number(s) :

Date Signed:

* For married individuals, the signature and Social Security Number of the spouse is required. This signature also authorizes the acceptance of the Criminal
Certification and allows consideration of the funds indicated herein for the HUD insured project.
form HUD-92417 (05/2003)
Page 4 of 4
ref. Handbook 4470.1