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PERSONAL FINANCIAL STATEMENT

Tab to each shaded field and type information.  Fields will expand as entry is typed.

Submitted to:   

Date:

IMPORTANT:  Read these directions before completing this Statement

If you are applying for individual credit in your own name and are relying on your own income, or assets and not the income or assets of

     another person as the basis for repayment of the credit requested, or if this statement relates to your guaranty of the indebtedness of other

     person(s), firm(s), or corporation(s), complete only Sections 1, 3, and 4.

If you are applying for individual credit but are relying on income from alimony, child support, or separate maintenance or on the income or

     assets of another person as a basis for repayment of the credit requested, complete all Sections.  Provide information in Section 2 about the

     person whose alimony, support, or maintenance payments or income or assets you are relying on.  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.

Section 1 – Individual Information

Section 2 – Other Party Information

Name

Name

Address

Address

City, State & Zip

City, State & Zip  

Social Security #

Social Security #  

Date of Birth

Date of Birth  

Position or occupation

Position or occupation  

Business name

Business name  

Business address

Business address

City, State & Zip

City, State & Zip  

Length at present address

Length at present address

Length of employment

Length of employment  

Res. Phone                  Bus. Phone

Res. Phone     Bus. Phone

Have (either of) you or any firm in which you were a major owner ever declared bankruptcy, or settled any debts for less than the amounts owed?  If yes, please provide details on a separate sheet.                                                                                                                                                                             

Are (either of) you a defendant in any suit or legal action?                                                                                                           Yes      No

Are (either of) you presently subject to any unsatisfied judgments to tax liens?                                                                           Yes      No

When, if ever, have (either of) you been audited by IRS?       Date:                                                              Yes      No

Are (either of) your assets held in a Trust?   Yes    No   If so, what type?    Living   Revocable   Non-Revocable   Other

Section 3 – Statement of Financial Condition as of              ,

Assets

(Do not include assets of doubtful value)

In dollars

(omit cents)

[Individual]

[Joint]

If joint, with whom

Liabilities

In dollars

(omit cents)

[Individual]

[Joint]

If joint, with whom

Cash, Checking & Savings, CD’s – see Schedule A

Notes payable to banks & others – see Schedule H

U.S. Gov’t & marketable securities – see Schedule B

Due to brokers

Non-marketable securities – see Schedule B

Amounts payable to others – secured

Securities held by broker in margin accounts

Amounts payable to others – unsecured

Restricted, control or margin account stocks

Accounts & bills due

Real estate owned – see Schedule D

Unpaid income tax

Accounts, loans, & notes receivable

Other unpaid taxes & interest

Automobiles

Real estate mortgages payable – see Schedules D & H

Cash surrender value-life insurance – see Schedule E

Vested interest in deferred compensation/profit-sharing plans – see Schedule F

Business ventures – see Schedule G

Other assets/personal property itemize – see Schedule G if applicable

Total Liabilities

Net Worth

Total Assets

Total Liabilities & Net Worth

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