Can this form be signed electronically?

Yes. Electronic signatures are generally enforceable under the ESIGN Act (15 U.S.C. §7001) and UETA (adopted by most states). Confirm recipient acceptance and any industry exceptions before eSigning.

Is notarization required?

Not always. Notarization depends on recipient or state requirements. Some lenders or jurisdictions require a notarized signature or a Remote Online Notarization with identity proofing and recording.

What authentication level is recommended?

Use email plus SMS or knowledge-based authentication for higher-risk recipients. For FDA or 21 CFR Part 11 contexts, require stronger controls and documented signer authentication.

How should supporting documents be attached?

Attach numbered, clearly labeled schedules with cross-references to the statement. Provide originals or certified copies when requested by auditors or regulators.

What happens if a figure changes after signing?

Prepare an amended statement or addendum signed and dated by authorized personnel; retain both versions and document the reason for change for audit trails.

How long will recipients expect you to retain copies?

Retain for at least the active term plus 3 years; federal and industry rules may require longer retention such as IRS three years (IRC §6501(a)) or HIPAA six years (45 CFR §164.530(j)).

Electronic Signature
Templates
Finance
Financial Statement of Assurance

Financial Statement of Assurance

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

FINANCIAL STATEMENT OF ASSURANCE

Identification

Issuer Name:

Principal Place of Business

Employer Identification Number (EIN/Tax ID):

Reporting Period From: To:

Entity Type

Corporation LLC Partnership

Sole Proprietorship Other:

Basis of Preparation

The financial statements presented for the Reporting Period have been prepared on the following basis (check all that apply):

Generally Accepted Accounting Principles (GAAP)

International Financial Reporting Standards (IFRS)

Cash Basis Tax Basis

Other Basis (if applicable)

Selected Financial Data

Enter amounts in U.S. dollars. Provide figures for the reporting period and, where available, the prior period.

Description	Current Period	Prior Period
Total Assets
Total Liabilities
Net Equity (Deficit)
Total Revenue
Total Expenses
Net Income (Loss)

Notes and Material Disclosures

Summary of Significant Accounting Policies and Material Notes Attachments and Schedules Included

Representations and Warranties

The undersigned, being duly authorized on behalf of the Issuer, represents and warrants that to the best of the Issuer's knowledge, the financial information provided in this Financial Statement of Assurance and the accompanying schedules and attachments are true, complete and prepared in accordance with the stated Basis of Preparation. All material transactions and events occurring during the Reporting Period have been recorded or disclosed and there are no undisclosed liabilities or contingencies that would materially affect the presented financial position.

The Issuer further represents that it has disclosed all related-party transactions, significant subsequent events, and any material breaches of covenant or default under financing agreements known to the Issuer as of the date of this statement.

Limitation of Liability and Reliance

This Statement of Assurance is provided for the limited purpose of permitting the Recipient to evaluate the Issuer's financial condition for the stated Reporting Period. Any third party relying on this statement does so at its own risk. Except as expressly agreed in a written engagement letter signed by an authorized representative of the Issuer, no auditor or independent accountant has performed an audit or review; consequently, no assurance is expressed beyond the Issuer's certification herein. The Issuer's liability for any claims arising from this Statement is limited to direct damages and excludes consequential, incidental, or punitive damages to the full extent permitted by law.

Certification

I certify that I am an authorized officer of the Issuer and that the information contained in this Financial Statement of Assurance, together with any attachments and schedules, is accurate and complete to the best of my knowledge and belief. I acknowledge that willful misrepresentation of material facts in this certification may subject me to civil or criminal penalties under applicable law.

Authorized Officer Name Title / Position Contact Phone Contact Email

Prepared By (if different from Issuer)

Preparer Name Preparer Firm (if applicable) Preparer Contact

Printed Name:

Signature:

Date:

What the Financial Statement of Assurance Is and when it’s used

A Financial Statement of Assurance is a signed declaration by a company, officer, or independent preparer that specified financial information is presented accurately for a defined period. It documents the preparer’s representations, discloses material assumptions and limitations, and attaches schedules or supporting statements. The form is commonly provided to lenders, auditors, regulatory bodies, or counterparties to confirm balances, covenant compliance, or the absence of undisclosed liabilities. When executed correctly it becomes a formal record used in underwriting, audits, regulatory reviews, and contractual negotiations.

Why a clear Financial Statement of Assurance matters

A clear, complete Financial Statement of Assurance reduces ambiguity about financial representations, supports third‑party reliance, and documents who is responsible for the assertions made. It provides an auditable record that can limit disputes and speeds administrative review.

Who typically prepares or receives this statement

Common preparers and recipients vary by use case but share a need for verified financial assertions.

Corporate officers and controllers preparing company attestations for lenders or auditors.
External accountants or financial advisors issuing limited-scope assurance schedules.
Lenders, underwriters, and counterparties who rely on confirmed financial facts.

Roles named above may have additional signature or authentication requirements depending on the receiving party and governing law.

Core components to include in a professional statement

Assemble the statement so each required element appears clearly and can be independently verified by reviewers.

Statement header

Identify the document as a Financial Statement of Assurance, include issuer name, recipient, and reporting period to define scope and applicability.

Certification clause

A concise attestation signed by an authorized representative stating truthfulness, accuracy, and any limitations or exceptions to the assertions.

Financial schedules

Attach schedules or line-item details (assets, liabilities, revenue, receivables) that support the high-level figures referenced in the certification.

Supporting notes

Disclose material accounting policies, estimates, related-party items, and contingencies that materially affect reported figures.

Signatory block

Include printed name, title, organization, date, and signature area for each authorized signer and, if required, witness or notary fields.

Attachments

Add corroborating documents such as bank confirmations, reconciliations, or management representations to substantiate key amounts.

Security and compliance considerations for electronic handling

Encryption in transit: TLS 1.2/1.3

Encryption at rest: AES-256

Audit trail: Tamper-evident timestamping

Regulatory certifications: SOC 2 Type II

Health-data support: HIPAA BAA available

Signature law: ESIGN and UETA compliant

Step-by-step: filling and finalizing the statement

Follow this order to prepare a complete, reviewable statement and avoid common rework.

01

Gather source records: Collect reconciliations, bank statements, and invoices.
02

Populate schedules: Complete line items and attach supporting documents.
03

Review and certify: Authorized officer verifies figures and signs.
04

Deliver to recipient: Provide signed PDF and retention copy to addressee.

Configuring an online workflow for submission

Set up fields, authentication, and routing before sending to ensure secure, auditable delivery.

Field	Configuration
File format	PDF preferred for fixed layout
Field detection	Enable automatic field mapping where available
Signer authentication	Choose email or SMS code per recipient risk level
Audit trail	Enable detailed logging and retention

Where to send the completed Financial Statement of Assurance

Direct routing depends on the receiving party and required delivery method; prepare copies for each stakeholder.

Lender or underwriter: Submit signed PDF with supporting schedules to the loan officer or secure portal
External auditor: Provide to audit contact and retain evidence of delivery
Regulatory agency: Follow agency filing instructions for format and filing channel
Internal records: Store a signed copy in enterprise records management system

Technical and interoperability checklist

Confirm platform capabilities and file formats before eSubmission to avoid rejections.

Formats supported: PDF, DOCX, XLSX
Integrations: Salesforce, NetSuite, Google Workspace
Authentication: Email, SMS, KBA options

Use a solution that provides audit trails, encryption, and the authentication level required by the recipient or applicable regulation.

Timing and processing expectations for delivery and retention

Understand submission timing and statutory retention triggers to meet lender, tax, or regulatory deadlines.

Provide on request:

Deliver promptly when a lender or regulator requests supporting assurance.

Annual reporting cadence:

Align statement periods to fiscal year or lender covenant schedule.

Tax audit readiness:

Retain supporting records for IRS retention periods when tax items are involved.

Notarization timing:

Schedule notary or RON before final signature if required by recipient.

Processing turnaround:

Allow reviewers 3–10 business days for verification, depending on scope.

Common mistakes that delay acceptance

Incomplete schedules or missing supporting documents that prevent independent verification and trigger follow-up requests.
Mismatched signer names or titles that fail identity checks or conflict with corporate records and banking details.
Inconsistent reporting periods between the statement and attached financial schedules, creating ambiguity for reviewers.
Using informal or altered certification language when the recipient requires specific attestation text or legal wording.

Key risks and potential penalties for incorrect statements

Tax reporting exposure: IRC §6721 fines

Regulatory enforcement: Agency sanctions possible

Contract breach risk: Remedies or damages may follow

Fraud allegations: Criminal or civil liability

Reputational harm: Loss of creditor trust

Audit rework: Additional costs to remediate

eSignature vendor comparison for executing and delivering Financial Statement of Assurance

Key vendor features and starting prices for eSignature platforms; signNow appears first per vendor ordering rules.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently asked questions about completing and delivering the statement

Answers to common questions on format, signature validity, notarization, and electronic delivery to reduce common processing delays.

Need help? Contact support

Can this form be signed electronically?
Yes. Electronic signatures are generally enforceable under the ESIGN Act (15 U.S.C. §7001) and UETA (adopted by most states). Confirm recipient acceptance and any industry exceptions before eSigning.
Is notarization required?
Not always. Notarization depends on recipient or state requirements. Some lenders or jurisdictions require a notarized signature or a Remote Online Notarization with identity proofing and recording.
What authentication level is recommended?
Use email plus SMS or knowledge-based authentication for higher-risk recipients. For FDA or 21 CFR Part 11 contexts, require stronger controls and documented signer authentication.
How should supporting documents be attached?
Attach numbered, clearly labeled schedules with cross-references to the statement. Provide originals or certified copies when requested by auditors or regulators.
What happens if a figure changes after signing?
Prepare an amended statement or addendum signed and dated by authorized personnel; retain both versions and document the reason for change for audit trails.
How long will recipients expect you to retain copies?
Retain for at least the active term plus 3 years; federal and industry rules may require longer retention such as IRS three years (IRC §6501(a)) or HIPAA six years (45 CFR §164.530(j)).

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