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PERSONAL INFORMATION - CO-APPLICANT
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Note: Complete Co-Applicant Sections if This Statement Supports a Joint Application
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Applicant Name:
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Employer:
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Address of Employer:
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Business Phone No.
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No. of Years with Employer:
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Title / Position:
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Name of Previous Employer:
(if with current employer less than 3 yrs.)
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No. Years with Previous Employer:
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Home Address:
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Home Phone:
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Social Security Number:
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Date of Birth:
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Name of Your Accountant:
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Phone Number of Your Accountant:
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Name of Your Attorney:
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Phone Number of Your Attorney:
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Name of Your Investment Advisor / Banker:
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Phone of Your Investment Advisor / Banker:
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Name of Your Insurance Advisor:
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Phone of Your Insurance Advisor:
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CASH INCOME & EXPENDITURES STATEMENT FOR YEAR ENDED
(omit cents)
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Annual Income
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Amount
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Salary (applicant):
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Salary (co-applicant):
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Bonuses & Commissions (applicant):
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Bonuses & Commissions (co-applicant):
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Rental Income:
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Interest Income:
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Dividend Income:
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Capital Gains:
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Partnership Income:
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Other Investment Income:
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Other Income (List)**:
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Total Income:
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** 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.
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Annual Expenditures
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Amount
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Federal Income & Other Taxes:
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State Income and Other Taxes:
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Rental Payments, Co-op, or Condo Maintenance:
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Mortgage Payments:
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Residential:
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Investment:
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Property Taxes:
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Residential:
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Investment:
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Insurance:
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Investments (including tax shelters):
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Alimony / Child Support:
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Tuition:
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Other Living Expense:
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Medical Expenses:
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Other Expense (List):
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Total Expenditures:
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Any significant changes expected in the next 12 months:
Yes No
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If yes, explain:
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Assets
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Amount
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Cash in this bank:
(including money market accounts, CD's)
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Cash in Other Financial Institutions (List):
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1)
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2)
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3)
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4)
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Readily Marketable Securities (Schedule A):
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Non-Readily Marketable Securities (Schedule A):
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Accounts and Notes Receivable:
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Net Cash Surrender Value of Life Insurance (Schedule B):
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Residential Real Estate (Schedule C):
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Partnerships / PC Interests (Schedule D):
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IRA, Keogh, Profit-Sharing & Other Vested Retirement Accounts:
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Deferred Income:
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Number of Years Deferred:
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Personal Property (including automobiles):
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Other Assets (List):
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1)
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2)
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3)
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4)
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Total Assets:
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Liabilities
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Amount
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Notes Payable to this bank:
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Secured:
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Unsecured:
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Notes Payable to Others (Schedule E):
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Secured:
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Unsecured:
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Accounts Payable (including credit cards):
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Margin Accounts:
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Notes Due: Partnership (Schedule D):
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Taxes Payable:
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Mortgage Debt (Schedule C):
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Life Insurance Loans (Schedule B):
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Other Liabilities (List):
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1)
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2)
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3)
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4)
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Total Liabilities:
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Net Worth:
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Contingent Liabilities
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Yes
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No
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Amount
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1) Are you a guarantor, co-maker, or endorser for any debt of an individual, corporation, or partnership?:
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2) Do you have any outstanding letters of credit or surety bonds?:
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3) Are there any suits or legal actions pending against you?:
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4) Are you contingently liable on any lease or contract?
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5) Are any of your tax obligations past due?
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6) What would be your total estimated tax liability if you were to sell your major assets?
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7) If yes for any of the above, give details:
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SCHEDULE A - ALL SECURITIES (including non-money market mutual funds)
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Readily Marketable Securities (including U.S. Governments and Municipals)
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