If an individual is married, please note the following:

All assets and liabilities, except the ownership interest in the firm, should be

halved accordingly on the form if jointly held. If assets and liabilities are separately owned, these items should only be reported on the respected owner’s form.

          EXAMPLES:

          John and Mary Smith jointly own their primary residence valued at

          $200,000.  They each claim 50% ownership on the property. John would

          only report his 50% interest, $100,000, on his Personal Net Worth

          Statement.

          Mary Smith has a vacation home in another state valued at $200,000.

          She owns the vacation home in its entirety. John would not report this on

          his Personal Net Worth Statement.

 Note: The West Virginia Department of Transportation (WVDOT) will exclude an individual’s ownership interest in his or her firm and the individual equity in his or her primary residence.  However, you must  provide this information.

ASSETS

Cash on hand & banks:

Enter the amount of cash on-hand in your checking accounts.

Savings Account:

Enter the total cash in all savings accounts.

IRA or other Retirement Accounts:

Enter the total value of all IRAs and other retirement accounts, including any Deferred Compensation and Pension Plans. You may be requested by WVDOT to provide copies of the most recent statements to substantiate the amount listed.

Accounts & Notes Payable

Enter the total value of all monies owed to you personally, if any.  This should include shareholder loans to the applicant firm.

Life Insurance:

Enter the cash surrender value of any life insurance policies. **A complete description is required in Section 8.

Stocks and Bonds:

Enter the current market value of your stocks/bonds. ** A complete listing and description is required in Section 3.

Real Estate:

Enter the current fair market value of all real estate owned. **A complete listing and description of all real estate owned is required in Section 4.

Automobile:

Enter the current fair market value of all automobiles owned.

Other Personal Property:

Enter the current fair market value of all other personal property owned, but not included in the previous sections. (i.e. furniture, jewelry, etc.) ** A complete description of these assets is required in Section 5.

Other Assets:

Enter the current fair market value of all other assets owned, but not included in the previous sections. ** A complete description of these assets is required in Section 5.

LIABILITIES

Accounts Payable:

Enter the total value of all unpaid accounts payable that is your responsibility. (i.e. gas, electric, telephone bills, etc.)

Notes Payable to Bank and Others:

Enter the total amount due on all Notes Payable to Banks and others, paid on an installment basis. Please be sure to indicate the total monthly payment in the space provided. This should include the amount of any loans from the applicant firm. This should not, however, include any mortgage balances. **A complete description of all installment accounts is required in Section 2.

Loans on Life Insurance:

Enter the total value of all loans due on Life Insurance Policies. **A complete description is required in Section 8.

Mortgages on Real Estate:

Enter the total value due on all mortgage(s) payable on Real Estate. **A complete breakdown of all mortgage(s) on Real Estate is required in Section 4.

Unpaid Taxes:

Enter the total amount of all taxes that are currently due, but are unpaid. Contingent tax liabilities or anticipated taxes for current year should not be included. **A complete description is required in Section 6.

Other Liabilities:

Enter the total value due on all other liabilities not classified in the previous section. **A complete description is required in Section 7.

Ownership Interest in Firm:

Enter the current fair market value of your portion of the ownership interest/equity in the business on this line (i.e. if your sole proprietorship is worth $40,000, this entire amount should be indicated.)

Equity in Primary Residence

Enter the difference between the present market value of your primary residence and your current mortgage balance.

SECTION 1. SOURCE OF INCOME

Salary:

Enter the amount of your total annual salary. This includes any salary from the applicant firm and if applicable, any salary from outside employment.

Net Investment Income:

Enter the total amount of all investment income. (i.e. dividends, interest, etc.)

Real Estate Income:

Enter the total amount of all real estate income received from the sale, rental, lease, etc. of real estate held.

Other Income:

Enter the total amount of all other income received (i.e. alimony, Social Security, Pension, etc.) Please be sure to describe the source of the other income in the space provided below in this section.

CONTINGENT LIABILITIES

As Endorser or Co-Maker:

Enter the total potential liabilities due as a result of being a co-signer for a loan or other commitments.

Legal Claims and Judgments:

Enter the potential liabilities due as a result of legal claims from judgments, lawsuits, etc.

Provisions for Federal Income Tax:

Enter the total amount of all Federal taxes for which you are potentially liable due to an anticipated gain on the pending sale of an asset or other circumstances, such as pending disputes or litigation which could possibly result in a personal tax liability.

Other Special Debt:

Enter the total amount due on all remaining potential debts not accounted for.

SECTION 2. NOTES PAYABLE TO BANKS AND OTHERS

Enter the name and address of note holder(s), original balance, current balance, payment amount, frequency, and how secured for each note payable as entered in the “Liabilities” column.

SECTION 3. STOCKS AND BONDS

Enter the number of shares, names of securities, cost, fair market value, and the date of fair market value for all shares of stocks and bonds held.

SECTION 4. REAL ESTATE OWNED

Starting with your primary residence, enter the type of property, address, date of purchase, original cost, present fair market value, name and address of mortgage holder, mortgage account number, mortgage balance, amount of payment, and status of mortgage for all real estate held.  Second mortgages also should be included in this section. Please ensure that this section contains all real estate owned, including rental properties, commercial properties, etc.

These values should correspond with the “Real Estate” amount listed in the “ASSETS” column.  Additionally, these values should correspond with the “Mortgages on Real Estate” amount listed in the “LIABILITIES” column.

SECTION 5. OTHER PERSONAL PROPERTY

Describe the “Other Personal Property” and “Other Assets” owned as listed in the “ASSETS” column.

SECTION 6. UNPAID TAXES

Describe in detail, as to the type, to whom payable, when due, amount, and to what property, if any, the tax lien attaches.  Please refer to the unpaid taxes listed in the “LIABILITIES” column. If none, state NONE.  This section should not include the contingent tax liabilities or anticipated taxes owed for the current year.

SECTION 7. OTHER LIABILITIES

Describe in detail any other liabilities as referenced by the value listed in the “LIABILITIES” column.  If none, state NONE.

SECTION 8. LIFE INSURANCES HELD

Describe all life insurance policies held. Please be sure to include the face amount of the policies, name of insurance company, beneficiaries and cash surrender values of the policies.

          Checklist:

          1.  Did you sign the Personal Financial Statement?

          2.  Did you provide your Social Security Number?

          3.  Did you sign the Affidavit in front of a Notary Public?

          4.  Did you enclose the U. S. Individual Income Tax Returns

            ( signed and dated) and W-2 Wage and Tax Statements for the

              previous three years.

Affidavit of Personal Net Worth

          The Federal Regulations 49 CFR Part 26.67(2)(i) require each individual owner of a firm applying to participate as a DBE whose ownership and control are relied upon, to submit a signed, notarized statement of Personal Net Worth (PNW), with appropriate documentation.  Appropriate supporting documentation generally includes, but is not limited to “U.S. Individual Income Tax Returns” and other documents to support statements contained in the “Personal Net Worth Statement.”  Contingent liability does not reduce an individual’s net worth.

          The undersigned swears, under penalty of the perjury laws of the United States, that the foregoing statements are true and correct and include all material information necessary to identify and establish the applicant’s personal net worth.  Further, the undersigned swears that he or she is in fact socially and economically disadvantaged and that the applicant has halved all assets and liabilities, except his or her ownership interest in the firm.  Further, the undersigned agrees to permit the audit and examination of their personal and business records and files to verify the accuracy of the statements made.  Any material misrepresentation will be grounds for terminating eligibility as well as any contract that may be awarded and for initiating action under Federal and/or State laws concerning false statements.

_______________________________________________________________________

Name of Firm

______________________________________                _______________________

                    Printed Name                                                           Title

______________________________________                _______________________

                    Signature                                                                 Date

On this _______ day of ________________, ____________________ before me appeared _________________________________________________________ who, being duly sworn, did execute the foregoing affidavit, and did state that he or she was properly authorized by _____________________________________ to execute the affidavit and did so as his or her free act and deed.

Notary Public _________________________Commission expires: ____________ {Seal}