Personal Financial Statement
Personal Financial Statement
CONFIDENTIAL
TYPE OF CREDIT - CHECK THE APPROPRIATE BOX Individual - If you check this box, provide financial information only about yourself. Joint - If you check this box, provide financial information about yourself and the other person.
Name Address City SSN Occupation
State DOB
Email
Name Address City SSN Occupation
Zip Phone
Complete all of Section 11 before Section 1. ASSETS 1 Cash On Hand and In Banks Sec. 11-A 2 Cash Value of Life Insurance Sec. 11-B 3 U.S. Gov. Securities Sec. 11-C 4 Other Marketable Securities Sec. 11-C 5 Notes & Accounts Receivable - Good Sec. 11-D 6 Other Assets Readily Convertible to Cash - Itemize 7 U.S. Savings Bonds 8 9 10 TOTAL CURRENT ASSETS 11 Real Estate Owned Sec. 11-E 12 Mortgages & Contracts Owned Sec. 11-F 13 Notes & Accounts Receivable - Doubtful Sec. 11-D 14 Notes Due From Relatives & Friends Sec. 11-D 15 Other Securities - Not Readily Marketable Sec. 11-C 16 Personal Property Sec. 11-G 17 Other Assets - Itemize 18 19 20 TOTAL ASSETS
0
ESTIMATE OF ANNUAL EXPENSES Income Taxes $ Other Taxes $ Insurance Premiums $ Mortgage Payments $ Rent Payable $ Other Expenses $ $ $ $ TOTAL $
$0 0 0 0
0 0
0 0 0
0 0 0
0
CONTINGENT LIABILITIES As Endorser, Co-maker or Guarantor $ On Leases or Contracts $ Legal Claims
Yes
Federal - State Income Taxes Other -
$ $ $
SECTION 11
CASH IN BANKS AND NOTES DUE TO BANKS NAME OF BANK
NOTE: Any willful misrepresentation could result in a violation of Federal Law (Sec. 18 U.S.C. 1014)
0
0 0 0 0 0 0 0
Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation. Other Income of Other Person- Itemize $ $ TOTAL
Email
Zip Phone
LIABILITIES 21 Notes Due to Banks Sec. 11-A 22 Notes Due to Relatives & Friends Sec. 11-H 23 Notes Due To Others Sec. 11-H 24 Accounts & Bills Payable Sec. 11-H Federal State 25 Unpaid Income Taxes Due 26 Other Unpaid Taxes and Interest 27 Loans on Life Insurance Policies Sec. 11-B 28 Contract Accounts Payable Sec. 11-H 29 Cash Rent Owed 30 Other Liabilities Due within 1 Year - Itemize 31 32 33 TOTAL CURRENT LIABILITIES 34 Real Estate Mortgages Payable Sec. 11-E 35 Liens & Assessments Payable 36 Other Debts - Itemize 37 38 Total Liabilities 39 Net Worth (Total Assets minus Total Liabilities) 40 TOTAL LIABILITIES & NET WORTH
$0 0 0 0 0
Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation. Other Income - Itemize $ Provide the following information only if Joint Credit is checked above. Other Persons Salary, Bonuses & Commissions $
A
State DOB
SECTION 1
ANNUAL INCOME $ Salary, Bonuses & Commissions $ Dividends & Interest $ Rental & Lease Income (Net)
GENERAL INFORMATION Are any Assets Pledged? No Yes (See Section 11) Yes Are you a Defendant in any Suits or Legal Actions? No (Explain): Have you ever been declared Bankrupt in the last 10 years? No (Explain):
Date
(List all Real Estate Loans in Section 11-E) On Deposit Notes Due Banks COLLATERAL (If Any) & Type of Ownership
Type of Account Type of Ownership
$
Cash On Hand $ TOTALS $ (Enter Sec 1 Line 1)
$
$ (Enter Sec 1 Line 21)
LN001.02 Rev 01.04.15 Member FDIC
B
SECTION 11 (continued)
LIFE INSURANCE
(List only those Policies that you own) Face of Policy
COMPANY
$
$
TOTALS $
0 $
$
C
Policy Loan from Insurance Co
Cash Surrender Value
(Enter Sec 1 Line 2)
SECURITIES OWNED
Other Loans Policy as Collateral
0
(Enter Sec 1 Line 27)
(Including U.S. Gov’t Bonds and all other Stock and Bonds) DESCRIPTION Type of COST Indicate those Not Registered in Your Name Ownership
Face Value - Bonds No. of Shares Stock
Market Value U.S. Gov. Sec.
TOTALS $
NOTES AND ACCOUNTS RECEIVABLE When Due
MAKER/DEBTOR
0 $
0 $ (Enter Sec 1 Line 5)
REAL ESTATE OWNED TITLE IN NAME OF
if Others have an Ownership Interest) Present Value Date Original Description & Location of Real Estate Acquired Cost
Amount of Ins. Carried
G
MORTGAGES AND CONTRACTS OWNED
(Indicate by a
0
Name
MORTGAGE OR CONTRACT PAYABLE Maturity Payment To Whom Payable
Bal. Due
0
(Enter Sec 1 Line 34)
if Others have an Ownership Interest)
MAKER
PERSONAL PROPERTY
PROPERTY COVERED
Address
Starting Date
Date When New
Cost When New
Value Today
LOANS ON PROPERTY To Whom Payable
Bal. Due
0
0
(Enter Sec 1 Line 16)
ACCOUNTS AND BILLS CONTRACTS PAYABLE
(Other than Bank, Mortgage and Insurance Company Loans) PAYABLE TO
Other Obligors (If Any)
0
(Enter Sec 1 Line 12)
if Others have an Ownership Interest)
TOTAL $
NOTES
Balance Due
Maturity
Payment
TOTAL $ (Indicate by a
DESCRIPTION
H
SECURITY (IF ANY)
(Enter Sec 1 Line 14)
TOTAL $
0
(Enter Sec 1 Line 11)
Cont. Mtge.
0 (Enter Sec 1 Line 15)
0 $ (Enter Sec 1 Line 13)
Amount Pledged to Secured Loans
Indicate by a
TOTAL $
F
0 $
(Enter Sec 1 Line 4)
(Money Payable or Owed to You Individually-Indicate by a if Others have an Ownership Interest) Balance Due Bal. Due Notes Balance Due Original Amount Doubtful Accounts Rel. & Friends Good Accounts
TOTALS $
E
MARKET VALUE Not Readily Marketable SECURITIES
Market Value Marketable Sec.
(Enter Sec 1 Line 3)
D
BENEFICIARY
$
When Due
Notes Due to Rel. & Friends
TOTALS $
Notes Due ‘Others’ (Not Banks)
0
(Enter Sec 1 Line 22)
Accounts & Bills Payable
0
0 (Enter Sec 1 Line 23)
Contracts Payable
COLLATERAL (If Any)
0
(Enter Sec 1 Line 24) (Enter Sec 1 Line 28)
For the purpose of procuring credit from time to time, I/We furnish the foregoing as a true and accurate statement of my/our financial condition. Authorization is hereby given to the Lender to verify in any manner it deems appropriate any and all items indicated on this statement. In addition, each individual signing below authorizes the Lender to check their individual credit account and employment history and have a credit reporting agency prepare a consumer credit report on them. The undersigned also agree to notify the Lender immediately in writing of any significant adverse change in such financial condition.
DATE SIGNED
LN001.02 Rev 01.04.15
SIGNATURE
SIGNATURE
(Other Person If Applicable)
CONFIDENTIAL
TYPE OF CREDIT - CHECK THE APPROPRIATE BOX Individual - If you check this box, provide financial information only about yourself. Joint - If you check this box, provide financial information about yourself and the other person.
Name Address City SSN Occupation
State DOB
Name Address City SSN Occupation
Zip Phone
Complete all of Section 11 before Section 1. ASSETS 1 Cash On Hand and In Banks Sec. 11-A 2 Cash Value of Life Insurance Sec. 11-B 3 U.S. Gov. Securities Sec. 11-C 4 Other Marketable Securities Sec. 11-C 5 Notes & Accounts Receivable - Good Sec. 11-D 6 Other Assets Readily Convertible to Cash - Itemize 7 U.S. Savings Bonds 8 9 10 TOTAL CURRENT ASSETS 11 Real Estate Owned Sec. 11-E 12 Mortgages & Contracts Owned Sec. 11-F 13 Notes & Accounts Receivable - Doubtful Sec. 11-D 14 Notes Due From Relatives & Friends Sec. 11-D 15 Other Securities - Not Readily Marketable Sec. 11-C 16 Personal Property Sec. 11-G 17 Other Assets - Itemize 18 19 20 TOTAL ASSETS
0
ESTIMATE OF ANNUAL EXPENSES Income Taxes $ Other Taxes $ Insurance Premiums $ Mortgage Payments $ Rent Payable $ Other Expenses $ $ $ $ TOTAL $
$0 0 0 0
0 0
0 0 0
0 0 0
0
CONTINGENT LIABILITIES As Endorser, Co-maker or Guarantor $ On Leases or Contracts $ Legal Claims
Yes
Federal - State Income Taxes Other -
$ $ $
SECTION 11
CASH IN BANKS AND NOTES DUE TO BANKS NAME OF BANK
NOTE: Any willful misrepresentation could result in a violation of Federal Law (Sec. 18 U.S.C. 1014)
0
0 0 0 0 0 0 0
Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation. Other Income of Other Person- Itemize $ $ TOTAL
Zip Phone
LIABILITIES 21 Notes Due to Banks Sec. 11-A 22 Notes Due to Relatives & Friends Sec. 11-H 23 Notes Due To Others Sec. 11-H 24 Accounts & Bills Payable Sec. 11-H Federal State 25 Unpaid Income Taxes Due 26 Other Unpaid Taxes and Interest 27 Loans on Life Insurance Policies Sec. 11-B 28 Contract Accounts Payable Sec. 11-H 29 Cash Rent Owed 30 Other Liabilities Due within 1 Year - Itemize 31 32 33 TOTAL CURRENT LIABILITIES 34 Real Estate Mortgages Payable Sec. 11-E 35 Liens & Assessments Payable 36 Other Debts - Itemize 37 38 Total Liabilities 39 Net Worth (Total Assets minus Total Liabilities) 40 TOTAL LIABILITIES & NET WORTH
$0 0 0 0 0
Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation. Other Income - Itemize $ Provide the following information only if Joint Credit is checked above. Other Persons Salary, Bonuses & Commissions $
A
State DOB
SECTION 1
ANNUAL INCOME $ Salary, Bonuses & Commissions $ Dividends & Interest $ Rental & Lease Income (Net)
GENERAL INFORMATION Are any Assets Pledged? No Yes (See Section 11) Yes Are you a Defendant in any Suits or Legal Actions? No (Explain): Have you ever been declared Bankrupt in the last 10 years? No (Explain):
Date
(List all Real Estate Loans in Section 11-E) On Deposit Notes Due Banks COLLATERAL (If Any) & Type of Ownership
Type of Account Type of Ownership
$
Cash On Hand $ TOTALS $ (Enter Sec 1 Line 1)
$
$ (Enter Sec 1 Line 21)
LN001.02 Rev 01.04.15 Member FDIC
B
SECTION 11 (continued)
LIFE INSURANCE
(List only those Policies that you own) Face of Policy
COMPANY
$
$
TOTALS $
0 $
$
C
Policy Loan from Insurance Co
Cash Surrender Value
(Enter Sec 1 Line 2)
SECURITIES OWNED
Other Loans Policy as Collateral
0
(Enter Sec 1 Line 27)
(Including U.S. Gov’t Bonds and all other Stock and Bonds) DESCRIPTION Type of COST Indicate those Not Registered in Your Name Ownership
Face Value - Bonds No. of Shares Stock
Market Value U.S. Gov. Sec.
TOTALS $
NOTES AND ACCOUNTS RECEIVABLE When Due
MAKER/DEBTOR
0 $
0 $ (Enter Sec 1 Line 5)
REAL ESTATE OWNED TITLE IN NAME OF
if Others have an Ownership Interest) Present Value Date Original Description & Location of Real Estate Acquired Cost
Amount of Ins. Carried
G
MORTGAGES AND CONTRACTS OWNED
(Indicate by a
0
Name
MORTGAGE OR CONTRACT PAYABLE Maturity Payment To Whom Payable
Bal. Due
0
(Enter Sec 1 Line 34)
if Others have an Ownership Interest)
MAKER
PERSONAL PROPERTY
PROPERTY COVERED
Address
Starting Date
Date When New
Cost When New
Value Today
LOANS ON PROPERTY To Whom Payable
Bal. Due
0
0
(Enter Sec 1 Line 16)
ACCOUNTS AND BILLS CONTRACTS PAYABLE
(Other than Bank, Mortgage and Insurance Company Loans) PAYABLE TO
Other Obligors (If Any)
0
(Enter Sec 1 Line 12)
if Others have an Ownership Interest)
TOTAL $
NOTES
Balance Due
Maturity
Payment
TOTAL $ (Indicate by a
DESCRIPTION
H
SECURITY (IF ANY)
(Enter Sec 1 Line 14)
TOTAL $
0
(Enter Sec 1 Line 11)
Cont. Mtge.
0 (Enter Sec 1 Line 15)
0 $ (Enter Sec 1 Line 13)
Amount Pledged to Secured Loans
Indicate by a
TOTAL $
F
0 $
(Enter Sec 1 Line 4)
(Money Payable or Owed to You Individually-Indicate by a if Others have an Ownership Interest) Balance Due Bal. Due Notes Balance Due Original Amount Doubtful Accounts Rel. & Friends Good Accounts
TOTALS $
E
MARKET VALUE Not Readily Marketable SECURITIES
Market Value Marketable Sec.
(Enter Sec 1 Line 3)
D
BENEFICIARY
$
When Due
Notes Due to Rel. & Friends
TOTALS $
Notes Due ‘Others’ (Not Banks)
0
(Enter Sec 1 Line 22)
Accounts & Bills Payable
0
0 (Enter Sec 1 Line 23)
Contracts Payable
COLLATERAL (If Any)
0
(Enter Sec 1 Line 24) (Enter Sec 1 Line 28)
For the purpose of procuring credit from time to time, I/We furnish the foregoing as a true and accurate statement of my/our financial condition. Authorization is hereby given to the Lender to verify in any manner it deems appropriate any and all items indicated on this statement. In addition, each individual signing below authorizes the Lender to check their individual credit account and employment history and have a credit reporting agency prepare a consumer credit report on them. The undersigned also agree to notify the Lender immediately in writing of any significant adverse change in such financial condition.
DATE SIGNED
LN001.02 Rev 01.04.15
SIGNATURE
SIGNATURE
(Other Person If Applicable)
