| For Help Call 631-509-1718 |
|
| Fields marked (*) are mandatory. |
|
| Business Type Information | |
| Applicant Information |
|
| Applicant | |
| Social Security # | |
| Age | |
| Marital Status | |
| Residence Address | |
| City | |
| State | |
| Zip | |
| Business Address | |
| City | |
| State | |
| Zip | |
| Email Address | |
| Home Phone | |
| Work Phone | |
| Occupation or Business | |
| How long? | |
| Previous Surety? | |
| If yes, give name and reason for change | |
| Type of Bond | |
| Amount of Bond ($) | |
| Effective Date | |
| Complete name and address of Obligee | |
| FINANCIAL STATEMENT as of | |
| Select one | |
| Financial Information |
|
| ASSETS |
|
| Cash ($) | |
| List Banks below | |
| Stocks & Bonds ($) | |
| Describe | |
| Notes Receivable ($) | |
| Merchandise or Material in Stock ($) | |
| Accounts Receivable ($) | |
| Real Estate, Homestead A ($) | |
| Real Estate, Investment B ($) | |
| Furniture and Fixtures ($) | |
| Other Assets ($) | |
| TOTAL ASSETS ($) | |
| LIABILITIES |
|
| Accounts Payable ($) | |
| Taxes due & accrued ($) | |
| Notes Payable to Bank ($) | |
| Notes Payable to Others ($) | |
| Mortgage on Real Estate A ($) | |
| Mortgage on Real Estate B ($) | |
| Other Liabilities ($) | |
| Describe | |
| TOTAL LIABILITIES ($) | |
| Capital Stock (Paid in) ($) | |
| NET WORTH OR SURPLUS ($) | |
| TOTAL Liabilities / Net Worth ($) | |
| Sales / Income |
|
| GROSS SALES |
|
| Two Years Ago ($) | |
| Last Year ($) | |
| NET INCOME |
|
| Two Years Ago ($) | |
| Last Year ($) | |
| INDEMNITY |
|
| Probate Bond Information |
|
| Name of deceased (Ward) | |
| Date of death | |
| Date of Appointment | |
| (If over 6 months,please explain delay.) | |
| Is applicant indebted to the estate or trust? | |
| If yes,please explain | |
| Name and address of attorney (if none, do not write the bond; sumbit to our underwriters) | |
| Will the attorney remain involved throughout the duration of this estate? | |
| Assets of estate or trust (describe) | |
| Name, age, and health status of |
|
| Minor(s) | |
| Incompetent | |
| Applicant's relationship to |
|
| deceased | |
| ward(s) | |
| Applicant's Net Worth ($) | |
| Are guardianship funds to be used for support of ward? | |
| If Yes, approximately how much per month? ($) | |
| What is the source of the guardianship funds? (If the insurance settlement, do not execute the bond; instead refer it to an underwriter) | |
| Who are the heirs of this estate? | |
| Has anyone objected to the applicant's appointment as fiduciary? | |
| Will any going business (excluding farms) of the estate be continued by fiduciary? | |
| (If Yes, send a copy of court order.) |
|
| Is this bond required on the demand of an interested person? | |
| If Yes, who? | |
| Name and address of court | |
| What is the applicant's experience in handling fiduciary responsibilities? | |
| Additional Comments |
|
| Additional Comments | |