PERSONAL FINANCIAL STATEMENT	CONFIDENTIAL	
		
	IMPORTANT:  DIRECTIONS TO APPLICANT	
			
To:  			Read directions before completing Financial Statement.	
		Please check appropriate box	
Address:  			Individual credit—If relying on your own income and assets and not the	
    			income and assets of a spouse or another person as a basis for 	
    			extension or repayment or credit, complete the Financial Statement below 	
		only as itapplies to you, individually.  Do not provide any information 	
Personal Financial Statement as of			about a spouse or other person.  Sign the Financial Statement.	
				  (DATE)		Joint Credit	If applying for joint credit or for individual credit relying	
APPLICANT’S NAME(S):  				on income or assets of a spouse or another person 	
    				for extension and repayment of credit requested, 	
		Individual relying	complete the Financial Statement below.  Include  	
HOME ADDRESS  			upon income or	information about income, assets and liabilities of the 	
    			assets of spouse	spouse or other person.  Both Applicant and Spouse 	
    			or other person.	or Co-Applicant sign this statement.	
HOME PHONE  		Please do not leave any questions unanswered.  Use “no” or “none” where necessary.	

Assets	In Even Dollars	
Liabilities and Net Worth	In Even Dollars	
Cash on hand and in Banks—See Schedule A	$	Notes Payable:  This Bank—See Schedule A	$	
U.S. Government Securities—See Schedule B		Notes Payable:  Other Institutions—See 		
Listed Securities—See Schedule B		   Schedule A		
Unlisted Securities—See Schedule B		Notes Payable—Relatives		
Other Equity Interests—See Schedule B		Notes Payable—Others		
Accounts and Notes Receivable		Accounts and Bills Due		
Real Estate Owned—See Schedule C		Unpaid Taxes		
Mortgages and Land Contracts Receivable—		Real Estate Mortgages Payable—See 		
   See Schedule D		   Schedule C or D		
Cash Value Life Insurance—See Schedule E		Land Contracts Payable—See Schedule C or D		
Other Assets:  Itemize		Life Insurance Loans—See Schedule E		
		Other Liabilities:  Itemize		

		TOTAL LIABILITIES	$	
		NET WORTH	$	
TOTAL ASSETS	$	TOTAL LIABILITIES AND NET WORTH	$	

Sources of Income	In Even Dollars	
General Information	
Salary	$	Employer	
Bonus and Commissions		Position or Profession	No. Years	
Dividends		Employer’s Address	
Real Estate Income			Phone No.	
*Other Income:  Itemize		Partner, officer or owner in any other venture?     No    Yes	
		If so, explain:	
TOTAL	$		
*Alimony, child support or separate maintenance payments need not		
be disclosed unless relied upon as a basis for extension of credit.  If 	Are any assets pledged?    No    Yes  Detail in Schedule A	
disclosed, payments received under  court order  written 		
agreement  oral understanding.	Income taxes settled through (Date)	

Contingent Liabilities	In Even Dollars	
General Information (continued)	
As endorser, co-maker or guarantor	$	Are you a defendant in any suits or legal action?    No    Yes	
On leases		If so, explain:	
Legal claims		Have you ever taken bankruptcy?    No    Yes 	
Provision for federal income taxes		If so, explain:	
Other special debt, e.g., recourse or repurchase liability		Do you have a will?      No    Yes  With whom?	
		Do you have a trust?    No    Yes  With whom?	
TOTAL	$	Number of dependents ______  Ages _______________	

Schedule A:  Banks, Brokers, Savings & Loan Association, Finance Companies or Credit Unions.  List here the names of all the institutions at which you maintain a deposit account and/or where you have obtained loans.	
Name of Institution	Name on Account	Balance on Deposit	
High Credit	Amount Owing	Monthly Payment	Secured by What Assets	

							

	TOTAL		TOTAL				

Schedule B:  U.S. Governments, Stocks (Listed & Unlisted), Bonds (Gov’t & Comm.), and Partnership Interests (General & Ltd.)	
Number of 	Indicate:			Pledged	
Shares, Face Value (Bonds), or % of Ownership	1.  Agency or name of company issuing security or name
     of partnership
2.  Type of investment or equity classification
3.  Number of shares, bonds or % of ownership held
4.  Basis of valuation*	In Name of	*Market Value	Yes
()	No
()	

						

						
		TOTAL				
*If unlisted security or partnership interest, provide current financial statements to support basis for valuation.	

Schedule C:  Real Estate Owned (and related debt, if applicable)	
Description of	Title in 	Date 	Cost + 	Present 	Mortgage or Land Contract Payable	
Property or Address	Name Of	Acq.	Improvements	Mkt. Value	Bal. Owing	Mo. Payt.	Holder	

								

		TOTAL						

Schedule D:  Real Estate:  Mortgages & Land Contracts Receivable (and related debt, if applicable)	
Description of	Title in 	Date 	Balance	Monthly	Mortgage or Land Contract Payable	
Property or Address	Name Of	Acq.	Receivable	Payment	Bal. Owing	Mo. Payt.	Holder	

								

		TOTAL						

Schedule E:  Life Insurance Carried	
Name of Company	Face Amount	Cash Surrender Value	Loans	Beneficiary	

					
					
TOTAL					

I/we have carefully read and submitted the foregoing information provided on all three pages of this statement to the Bank named above.  The information is presented as a true and accurate statement of my/our financial condition on the date indicated.  This statement is provided for the purpose of obtaining and maintaining credit with said Bank.  I/we agree that if any material change(s) occur(s) in my/our financial condition that I/we will immediately notify said Bank of said change(s) and unless said Bank is so notified it may continue to rely upon this financial statement and the representations made herein as a true and accurate statement of my/our financial condition.

I/we authorize the Bank to make whatever credit inquiries it deems necessary in connection with this financial statement.  I/we authorize and instruct any person or consumer reporting agency to furnish to the Bank any information that it may have or obtain in response to such credit inquiries.

I/we also hereby certify that no payment requirements listed herein are delinquent or in default except as follows; if “NONE” so state.

I/we fully understand that it is a federal crime punishable by fine or imprisonment or both to knowingly make any false statements concerning any of the above facts, pursuant to 18 U.S.C. Section 1014.

Applicant’s 	Date	Social	Date of 	
Signature 		Signed 		Security No. 		Birth 		
Spouse’s or				
Co-Applicant’s 	Date	Social	Date of 	
Signature 		Signed 		Security No. 		Birth