Vending Manufacturer Treasure Chest

Accessit Corp
Net Worth Statement Form

For those applying for a Master Distributorship or Executive Platinum Distributorship.

To complete the assessment process of your application please fill out the following Net Worth Statement.

The following information submitted will be held totally confidential and to be used solely for the assessing of potential applicants by Accessit Corp.
Please state all values in US Dollars.

Date: 6/24/2017 3:35:14 PM
Name:
Phone:
Email:
Country:

Assets

Market Value
Cash On Hand: $
Checking Account(s):$
Savings Account(s): $
Money Market Funds / Money Market Deposit Accounts:$
Time Deposits:$
Savings Bonds:$
Investment Assets:
Stocks: $
Bonds: $
Mutual funds: $

Real Estate
Home: $
Other: $

Cash Value of Life Insurance/Annuities

$
Partnership and Business Interest$
Other: $

Retirement Assets:
IRA/Keogh Account$
Employee Retirement Fund: $
Other: $

Consumption Assets
Home Furnishings/Appliances$
Sports and Hobby Equipment$
Automobiles/Vehicles$
Other: $
Other
$
$
$

Liabilities

Market Value
Past-due Bills for Services, Rent, etc.$
Past-due Taxes$

Credit Cards/Charge Accounts

$
$
$
$
$

Consumer Installment Debt
Automobile$
$

Real Estate Debt
Home$
$

Pledges: Charities, Churches, etc.

$
Other
$
$

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Accessit Corp., Manufacturers & Producers, Winnipeg, MB


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