PERSONAL FINANCIAL STATEMENT - Slatt Capital



PERSONAL FINANCIAL STATEMENT

|NAME |AGE |SOCIAL SECURITY NO. |

|HOME ADDRESS |YRS. THERE |

|CITY |STATE |ZIP CODE |HOME PHONE |

| | | |( ) |

|EMPLOYER |WORK PHONE |

| |( ) |

|EMPLOYER ADDRESS |CITY |STATE |ZIP CODE |

|POSITION |YRS. THERE |SOCIAL SECURITY NO. |

|SPOUSE NAME |AGE | |

|HOME ADDRESS |YEARS THERE |

|CITY |STATE |ZIP CODE |HOME PHONE |

| | | |( ) |

|EMPLOYER |WORK PHONE |

| |( ) |

|EMPLOYER ADDRESS |CITY |STATE |ZIP CODE |

|POSITION |YRS. THERE | |

YOU MAY APPLY FOR CREDIT EXTENSION OR

FINANCIAL ACCOMMODATION SEPARATELY OR JOINTLY

Are you requesting this financial accommodation: ( Separately?

( Jointly with your spouse?

← Jointly with another person: (Please submit

separate financial statements attached together.)

Marital Status (answer only if this financial statement ( Married

is provided in connection with a request for secured ( Separated

Credit or if you live in a community property state, ( Unmarried (unmarried includes

such as California. single, divorced, widowed)

Reflect in this statement the financial condition of your spouse as well as your own financial condition if:

1. You are seeking this financial accommodation jointly with your spouse, or

2. You are relying on your spouse’s assets or income in requesting this financial accommodation, or

3. You live in a community property state like California

| | | |

|DATE OF STATEMENT____________, 20_____ | | *Please attach a separate sheet if you |

| | |need |

| | | more space to complete a detail |

| | |schedule. |

|ASSETS |AMOUNT |LIABILITIES |AMOUNT |

|Cash in Heritage Bank of Commerce | |Notes Payable to Heritage Bank of Commerce |

|Cash in Other Banks (Detail) | | | |

| | |Accounts Payable | |

| | | | |

| | | | |

|Accounts Receivable | |Notes Payable to Others (Schedule 7) | |

| | | | |

|Notes Receivable (Schedule 1) | |Income Taxes Payable | |

|Mortgages & Deeds of Trust Owned (Schedule 2) | |Other Taxes Payable | |

|Securities Owned (Schedule 3) | | | |

|Cash Surrender Value of Life Insurance (Schedule 4) | |Loans on Life Insurance (Schedule 4) | |

|Real Estate (Schedule 5) | |Mortgages or Liens on Real Estate (Schedule 6) | |

|Automobiles | |Installment Contracts Payable | |

| | |Credit and Charge Cards | |

|Personal Property | | | |

|IRA Account | |Other Liabilities (Detail) | |

|Other Assets (Detail) | | | |

| | | | |

| | | | |

| | | TOTAL | |

| | |LIABILITIES | |

| | | NET | |

| | |WORTH | |

| | | | |

|TOTAL | |TOTAL | |

| | | | | | |

|ANNUAL INCOME | |ANNUAL EXPENDITURES |CONTINGENT LIABILITIES |

|Employment Income | |Property Taxes | |As Endorser | |

| | |Income Taxes | |As Guarantor | |

|Dividends | |Mortgage P & I | |On Damage Claims | |

|Interest | |Contract Payments | |For Taxes | |

|Rentals (Schedule 5) | |Insurance | |Other (Detail) | |

|Alimony Child support | |Living Expense | | | |

|Other | |Alimony, Child support | | | |

| | |Other | | | |

| | | | | | |

| | | | |Θ Check here if "None" |

| | | | | | |

|Total |= |Total | |Total | |

|Income | |Expenditures | |Contingent Liabilities | |

| | | | | | |

|SCHEDULE 1 NOTES RECEIVABLE | | | |

|NAME OF DEBTOR |COLLATERAL |PAYABLE |MAURITY DATE |TOTAL AMOUNT DUE |

| | |$ per | | |

| | |$ per | | |

| | |$ per | | |

| | | | | |

| | | | TOTAL | |

|SCHEDULE 2 MORTGAGES AND DEEDS OF TRUST OWNED | | |

|NAME OF DEBTOR |LIEN POSITION |PROPERTY VALUE |PRIOR LIENS |HOW PAYABLE |MATURITY DATE |UNPAID BALANCE |

| | | | |$ | | |

| | | | |per | | |

| | | | |$ | | |

| | | | |per | | |

|SCHEDULE 3 SECURITIES OWNED | | | | | |

| |EXCHANGE | | | | |TOTAL |PLEDGED? |

| | | | | | | | |

| | | | | | | | |

| | | | | | | | |

| | | | | | | | |

| | | | | | | | |

| | | | | | | | |

| | | | | | | | |

| | | | | |TOTAL | | |

|SCHEDULE 4 LIFE INSURANCE | | | | |

|INSURED |FACE AMOUNT OF POLICY |INSURANCE COMPANY |BENEFICIARY |CASH VALUE |LOANS |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | TOTAL | |

|SCHEDULE 5 REAL ESTATE | | | | | |

| | |HOW HELD |COST |MONTHLY |PRESENT |TOTAL BALANCE OWED |

| | | |YEAR | | | |

| | | | | | | |

|2- | | |$ | | | |

| | | |YEAR | | | |

| | | | | | | |

|3- | | |$ | | | |

| | | |YEAR | | | |

| | | | | | | |

|4- | | |$ | | | |

| | | |YEAR | | | |

| | | | | | | |

| | | | | | | |

| | |TOTAL | | | | |

|SCHEDULE 6 MORTGAGES AND LIENS ON REAL ESTATE | | | |

|PROPERTY |INDICATE 1ST OR |INTEREST | |

|NO. |TO WHOM PAYABLE |2ND MORTGAGE |HOW PAYABLE |RATE |MAURITY DATE |BALANCE OWING |

| | | |$ Per | | | |

| | | |$ Per | | | |

| | | |$ Per | | | |

| | | |$ Per | | | |

| | | |$ Per | | | |

| | | |$ Per | | | |

|SCHEDULE 7 NOTES PAYABLE | | | |

|TO WHOM |ADDRESS |COLLATERAL |INTEREST RATE |UNPAID BALANCE |

| | | | | |

| | | | | |

|HOW HELD |COMMUNITY PROPERTY | SEPARATE PROPERTY (indicates applicable abbreviation) |

|CODES |ALWAYS INDICATE "CP" |"SO" = SINGLE OWNERSHIP |"JT" = JOINT TENANTS |"TIC" = TENANTS IN COMMON |

___________________________________________________________________

Yes No

( ( Have you filed Bankruptcy?

If yes, which chapter? (7 (11 (13

Filing Date: __________/_____________/___________

Discharge Date: ________/_____________/___________

If not, why?______________________________________

( ( Have you: Comprised a debt?

( ( Had a suit or judgment entered against you?

← ( Had a vehicle repossessed?

( ( If this is a statement of you and your spouse, are any assets your

spouse’s separate property?

What assets are held in Joint tenancy?

( ( Are any of your assets held in trust?

|CREDIT REFERENCE |NEAREST RELATIVE NOT LIVING WITH YOU |

|Name: |Name: |

|Address: |Address: |

|Phone: |Phone: |

|Name: |Name: |

|Address: |Address: |

|Phone: |Phone: |

The information on the pages of this form is submitted for the purpose of inducing Lender to extend credit and is a true, full and correct statement of my/our financial condition as of the date shown. I/we acknowledge and agree that the Lender will rely upon the information provided on this form and that intentionally false, incomplete or incorrect information may constitute fraud. While indebted to you, I/we agree to notify you immediately of any material change of my/our financial condition. In the event that such notification is not given, or if other acts occur that, in your opinion, either do or could adversely affect the Lender’s interest, then any and all outstanding obligations may, at your election, become due and payable without demand or notice and may be charged against any and all assets of the undersigned in possession or control of the Lender.

I authorize the Lender to check my credit references. I also authorize the Lender to provide credit information arising from this transaction to others as may be reasonably requested.

|Applicant’s Signature |Date |Co-Applicant’s Signature |Date |

| | |(Where Applicable) | |

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