Personal Financial Statement

PERSONAL INFORMATION - APPLICANT

Applicant Name:

 Employer:
Address of Employer:
 Business Phone No.
No. of Years with Employer:
 Title / Position:
Name of Previous Employer:
(if with current employer less than 3 yrs.)
 No. Years with Previous Employer:
Home Address:
 Home Phone:
Social Security Number:
 Date of Birth:
Name of Your Accountant:
 Phone Number of Your Accountant:
Name of Your Attorney:
 Phone Number of Your Attorney:
Name of Your Investment Advisor / Banker:
 Phone of Your Investment Advisor / Banker:
Name of Your Insurance Advisor:
 Phone of Your Insurance Advisor:
  
PERSONAL INFORMATION - CO-APPLICANT
Note: Complete Co-Applicant Sections if This Statement Supports a Joint Application

Applicant Name:

 Employer:
Address of Employer:
 Business Phone No.
No. of Years with Employer:
 Title / Position:
Name of Previous Employer:
(if with current employer less than 3 yrs.)
 No. Years with Previous Employer:
Home Address:
 Home Phone:
Social Security Number:
 Date of Birth:
Name of Your Accountant:
 Phone Number of Your Accountant:
Name of Your Attorney:
 Phone Number of Your Attorney:
Name of Your Investment Advisor / Banker:
 Phone of Your Investment Advisor / Banker:
Name of Your Insurance Advisor:
 Phone of Your Insurance Advisor:
 
CASH INCOME & EXPENDITURES STATEMENT FOR YEAR ENDED  
(omit cents)
Annual Income Amount

Salary (applicant):
Salary (co-applicant):
Bonuses & Commissions (applicant):
Bonuses & Commissions (co-applicant):
Rental Income:
Interest Income:
Dividend Income:
Capital Gains:
Partnership Income:
Other Investment Income:
Other Income (List)**:

Total Income:
 ** Income from alimony, child support, or maintenance income need not be revealed if the applicant or co-applicant does not wish to have it considered as a basis for repaying this obligation.  Alimony, child support or or separate maintenance received under:
Court Order   Written Agreement   Oral Understanding.

  
Annual Expenditures Amount
Federal Income & Other Taxes:
State Income and Other Taxes:
Rental Payments, Co-op, or Condo Maintenance:
Mortgage Payments:
 

Residential:

Investment:
Property Taxes:

Residential:
Investment:
Insurance:
Investments (including tax shelters):
Alimony / Child Support:
Tuition:
Other Living Expense:
Medical Expenses:
Other Expense (List):
Total Expenditures:
  
Any significant changes expected in the next 12 months:

Yes   No

 If yes, explain:
  

Assets

Amount
Cash in this bank:
(including money market accounts, CD's)
Cash in Other Financial Institutions (List):
1)
2)
3)
4)
Readily Marketable Securities (Schedule A):
Non-Readily Marketable Securities (Schedule A):
Accounts and Notes Receivable:
Net Cash Surrender Value of Life Insurance (Schedule B):
Residential Real Estate (Schedule C):
Partnerships / PC Interests (Schedule D):
IRA, Keogh, Profit-Sharing & Other Vested Retirement Accounts:
Deferred Income:
Number of Years Deferred:
Personal Property (including automobiles):
Other Assets (List):
1)
2)
3)
4)
Total Assets:
   

Liabilities

Amount
Notes Payable to this bank:
Secured:
Unsecured:
Notes Payable to Others (Schedule E):
Secured:
Unsecured:
Accounts Payable (including credit cards):
Margin Accounts:
Notes Due: Partnership (Schedule D):
Taxes Payable:
Mortgage Debt (Schedule C):
Life Insurance Loans (Schedule B):
Other Liabilities (List):
1)
2)
3)
4)
Total Liabilities:
Net Worth:
  
Contingent Liabilities Yes No Amount
1) Are you a guarantor, co-maker, or endorser for any debt of an individual, corporation, or partnership?:
2) Do you have any outstanding letters of credit or surety bonds?:
3) Are there any suits or legal actions pending against you?:
4) Are you contingently liable on any lease or contract?
5) Are any of your tax obligations past due?
6) What would be your total estimated tax liability if you were to sell your major assets?
7) If yes for any of the above, give details:
   
SCHEDULE A - ALL SECURITIES (including non-money market mutual funds)
 
Readily Marketable Securities (including U.S. Governments and Municipals)
No. of Shares (Stock) or Face Value (Bonds) Description Owner(s) Where Held Cost Current Market Value

Pledged
Yes No

  

Non-Readily Marketable Securities (closely held, thinly traded, or restricted stock)
No. of Shares (Stock) or Face Value (Bonds) Description Owner(s) Where Held Cost Current Market Value

Pledged
Yes No

     

SCHEDULE B - INSURANCE 

  

Life Insurance

Insurance Company

 Face Amount of Policy Type of Policy Beneficiary Cash Surrender Value Amount Borrowed

Ownership
             

Disability Insurance

 Applicant Co-Applicant

Monthly Distribution if Disabled:

Number of Years Covered:

  

SCHEDULE C - Personal Residence & Real Estate Investments, Mortgage Debt
(majority membership only) 

  

Personal Residence:

1) Property Address

Legal Owner

Purchase

Market Value

 Present Loan Balance Interest Rate Loan Maturity Date Monthly Payment

Lender
Year Price

  
2) Property Address Legal Owner

Purchase

Market Value

 Present Loan Balance Interest Rate Loan Maturity Date Monthly Payment

Lender
Year Price

   
3) Property Address Legal Owner

Purchase

Market Value

 Present Loan Balance Interest Rate Loan Maturity Date Monthly Payment

Lender
Year Price

  

Investment Property:
1) Property Address Legal Owner

Purchase

Market Value

 Present Loan Balance Interest Rate Loan Maturity Date Monthly Payment

Lender
Year Price

  
2) Property Address Legal Owner

Purchase

Market Value

 Present Loan Balance Interest Rate Loan Maturity Date Monthly Payment

Lender
Year Price

 
3) Property Address Legal Owner

Purchase

Market Value

 Present Loan Balance Interest Rate Loan Maturity Date Monthly Payment

Lender
Year Price

  

SCHEDULE D - PARTNERSHIPS
(less than majority ownership for real estate partnerships)
  
Business / Professional Investment:
1) Name Date of Initial Investment Cost Percent Owned Current Market Value Balance Due on Partnerships: Notes, Cash Call Final Contribution Date

   
2) Name Date of Initial Investment Cost Percent Owned Current Market Value Balance Due on Partnerships: Notes, Cash Call Final Contribution Date

 

Investments (Including Tax Shelters):
1) Name Date of Initial Investment Cost Percent Owned Current Market Value Balance Due on Partnerships: Notes, Cash Call Final Contribution Date

 
2) Name Date of Initial Investment Cost Percent Owned Current Market Value Balance Due on Partnerships: Notes, Cash Call Final Contribution Date

 
3) Name Date of Initial Investment Cost Percent Owned Current Market Value Balance Due on Partnerships: Notes, Cash Call Final Contribution Date

 

SCHEDULE E - Notes Payable
1) Due To Type of Facility Amount of Line Secured Collateral Interest Rate Maturity Unpaid Balance
Yes No

  
2) Due To Type of Facility Amount of Line Secured Collateral Interest Rate Maturity Unpaid Balance
Yes No
  
3) Due To Type of Facility Amount of Line Secured Collateral Interest Rate Maturity Unpaid Balance
Yes No
  
4) Due To Type of Facility Amount of Line Secured Collateral Interest Rate Maturity Unpaid Balance
Yes No

  

Please Answer the Following Questions:
1) Income tax returns filed through:

Are any returns currently being audited or contested?:
Yes  No

 If yes, what year(s):
 
2) Have (either of) you or any firm in which you were a major owner ever declared bankruptcy?
Yes  No		 If yes, please provide details:
  
3) Have you drawn a will?
Yes  No		 If yes, please furnish the name of the executor(s) and year will was drawn:
  
4) Number of dependents (excluding self) and relationship to applicant:
  
5) Have you ever had a financial plan prepared for you:

Yes  No
  
6) Did you include two years federal and state tax returns? Yes  No
 
7) Do (either of) you have a line of credit or or unused credit facility at any other institution(s)?
Yes  No		 If so, please indicate where, how much, and name of banker:
     
8) Do you anticipate any substantial inheritances?:
Yes  No		 If so, please explain:
 
REPRESENTATIONS AND WARRANTIES
The information contained in this statement is provided to induce you to extend or to continue the extension of credit to the undersigned or to others up the guarantee of the undersigned.  The undersigned acknowledge and understand that you are relying on the information provided herein in deciding to grant or continue credit or to accept a guarantee thereof.  Each of the undersigned represents, warrants and certifies that the information provided herein is true, correct and complete.  Each of the undersigned agrees to notify you immediately and in writing of any change in name, address, or employment and of any material adverse change (1) in any of the information contained in this statement or (2) in the financial condition of any of the undersigned or (3) in the ability of any of the undersigned to perform its (or their) obligations to you.  In the absence of such notice or a new and full written statement, this should be considered as a continuing statement and substantially correct.  If the undersigned fail to notify you are required above, or if any of the information herein should prove to be inaccurate or incomplete in any material respect, you may declare the indebtedness of the undersigned or the indebtedness guaranteed by the undersigned, as the case may be, immediately due and payable.  You are authorized to make all inquiries you deem necessary to verify the accuracy of the information contained herein and to determine the credit-worthiness of the undersigned.  The undersigned authorize any person or consumer reporting agency to give you any information it may have on the undersigned.  Each of the undersigned authorizes you to answer questions about your credit experience with the undersigned.  As long as any obligation or guarantee of the undersigned to you is outstanding, the undersigned shall supply annually an updated financial statement.  This personal financial statement and any other financial or other information that the undersigned give you shall be your property.
     
I agree to the above Representations and Warranties: Applicant
Co-Applicant