Personal Financial Statement

Personal Financial Statement
Section A - Applicant Information Section B – Co-Applicant Information

Name: Name:
Date of Birth Date of Birth:

Residence Address: Residence Address:
City, State, Zip Code:: City, State, Zip Code:
Year There: Year There:

Occupation: Occupation:
Business Name: Business Name:
Business Address: Business Address:
City, State, Zip Code: City, State, Zip Code:
Residence Phone: Residence Phone:
Business Phone: Business Phone:
Email Address: Email Address:
Name and Address of Nearest Relative (Not Living With You) Name and Address of Nearest Relative (Not Living With You)
Section C - Statement of Financial Condition as of:

Assets In Dollars Liabilities In Dollars
(Do not include Assets doubtful of Co- Co-
value) Applicant Applicant Applicant Applicant
Cash on hand and in banks Notes Payable to banks - secured

U.S. Gov't & Marketable Securities
(Schedule A) Notes Payable to banks - unsecured
Non-Marketable Securities (Schedule B) Due to Brokers
Securities held by broker in margin
accounts
Restricted or control stocks Amounts payable to others - secured

Partial interest in Real Estate Equities
(Schedule C) Amounts payable to others - unsecured
Real Estate Owned (Schedule D) Amounts and bills due
Loans Receivable Unpaid income tax
Other unpaid taxes and interest
Real Estate mortgages payable (Schedule
Cash Value Life Insurance (Schedule E) D)
Other Assets - itemize Other Debts
Vested PV Retirement Salary Cont - NPV
401K Retirement Plan
Total Liabilities
Net Worth
Total Assets Total Liabilities and Net Worth
Alimony, child support, or separation maintenance income need not be revealed if you do not wish to have it considered as a basis for
repaying this obligation.
Annual Income Personal Information
Source of Income for Year Ended PLEASE USE SEPARATE SHEET FOR ADDITIONAL DETAILS
Salary, bonuses & commissions Is any income listed likely to be reduced prior to the loan being paid off?
Dividends
Real Estate Income Are you a partner or officer in any other venture? If so, describe.
Other Income
Are you obligated to pay alimony, child support or separate maint.
payments?
Are any assets pledged other than as described on schedules? If so,

describe.
Total
CONTINGENT LIABILITIES
Do you have any contingent liabilities? If so describe Are you a defendant in any suits or legal actions?
Personal bank accounts carried at:
As endorser, co-maker or guarantor? Savings Account:
On leases or contracts? Checking Account:
Legal claims? Have you ever been declared bankrupt in the last 10 years? If Yes,
explain.
Other special debt
Amount of contested income tax liens
Schedule A - U.S. Government & Marketable Securities

Number of Shares
or Face Value
(Bonds) Description In Name of Are These Pledged? Market Value
Total
Schedule B - Non Marketable Securities
Number of Shares
or Face Value
(Bonds) Description In Name of Are These Pledged? Market Value
Total
Schedule C – Partial Interests in Real Estate Equities
Address & Type of % of Market
Property Title in Name of Ownership Date Acquired Cost Value Mortgage Maturity
1
2
3
4
5
Mortgage Balance Monthly Payment
1
2
3
4
5
Schedule D - Real Estate Owned
Title in Market
Address & Type of Property Name of Date Acquired Cost Value Mortgage Maturity
1
2
3
4
5
Mortgage Balance Monthly Payment
1
2
3
4
5
Schedule E - Life Insurance Carried, Including N.S.L.I. And Group Insurance
Name of Insurance Policy
Company Owner of Policy Beneficiary Face Amount Loans Cash Surrender Value
Schedule F - Banks or Finance Companies Where Credit Has Been Obtained
Name & Address Secured or High
of Lender Credit in The Name of Unsecured? Original Date Credit Current Balance
Section D - Secured Credit (Complete only if credit is to be secured)

List Names and Addresses of all owners of property to be pledged as collateral to secure credit requested. If security is real estate, give
full name of co-owner (ifany).
Name of Owner / Name of Owner / Co- Name of Owner / Co-
Co-Owners % Owned Owners % Owned Owners % Owned
The information contained in this statement is provided for the purpose of obtaining, or maintaining credit with you on behalf of the undersigned, or
persons, firms or corporation in whose behalf the undersigned may either severally or jointly with others executed a guaranty in your favor. Each
undersigned understands that you are relying on the information provided herein (including the designation made as to ownership of property) in
deciding to grantor continue credit. Each undersigned represents and warrants that the information provided is true and complete and that you may
consider this statement as continuing to be true and correct until written notice of a change is given to you by the undersigned. You are authorized to
make all inquires you deem necessary to verify the accuracy if the statements made herein, and to determine my/our credit worthiness. You are
authorized to answer questions about your credit experience with me/us.
Account Requested:
Individual Joint
We intend to apply for joint credit.
___________ ___________
Applicant Co-Applicant
Applicant
Signature:
SS#
Drivers License#
Date:
Co-Applicant
Signature:
SS#
Drivers License#
Date:

Personal Financial Statement

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Personal Financial Statement

Section A - Applicant Information Section B – Co-Applicant Information

Date of Birth Date of Birth:

Year There: Year There:

Section C - Statement of Financial Condition as of:

Cash on hand and in banks Notes Payable to banks - secured

Restricted or control stocks Amounts payable to others - secured

Are any assets pledged other than as described on schedules? If so,

Schedule A - U.S. Government & Marketable Securities

Section D - Secured Credit (Complete only if credit is to be secured)

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