First Community Bank - Texas Citizens Bank | Business Bank



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Personal Financial Statement

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|Dated as of_______________________, 20________. |

|Name |Social Security No. |TDL # |___Unmarried * |Number of Dependents |

| | | |___Married ___Separated | |

|Spouses Name |Spouses Social Security No. |Spouses TDL # |___Joint Statement ___Individual Statement |

|Home Address |City |Phone |How Long |

| |Zip | | |

|Employer |How Long |Business Address |Phone |Occupation/Position |

|SECTION A: ASSETS |SECTION B: LIABILITIES |

|CASH | |REAL ESTATE/MORTGAGES PAYABLE (Sch. 5) | |

|(Sch. 1) | | | |

|MARKETABLE SECURITIES (Sch. 2) | |NOTES PAYABLE | |

| | |(Sch. 8) | |

|NON-MARKETABLE SECURITIES (Sch. 3) | |MARGIN DEBT DUE BROKERS (Sch. 2) | |

|INVESTMENTS IN PARTNERSHIPS (Sch. 4) | |PARTNERSHIP RELATED DEBT (Sch. 4) | |

|REAL ESTATE (HOMESTEAD) (Sch. 5) | |TAXES PAYABLE | |

|REAL ESTATE (OTHER) (Sch. 5)| |CREDIT CARD DEBT | |

|IRA’S, KEOGHS, & OTHER QUALIFIED PLANS | |OTHER LIABILITIES | |

|(Sch. 6) | | | |

|OTHER ASSETS | | | |

|(Sch. 7) | | | |

|PERSONAL PROPERTY | | | |

|AUTOMOBILES | | | |

|NOTES RECEIVABLE | | | |

|INTERESTS IN TRUSTS | | | |

|MISCELLANEOUS | | | |

| | |TOTAL LIABILITIES | |

| | |NET WORTH | |

|TOTAL ASSETS | |TOTAL LIABILITIES PLUS NET WORTH | |

|SECTION C: CASH INCOME AND CASH EXPENSE INFORMATION ** |

|CASH INCOME ** |LAST YEAR |THIS YEAR |CASH EXPENSES *** |LAST YEAR |THIS YEAR |

|GROSS WAGES OR SALARIES | | |REAL ESTATE/MORTGAGE PAYMENTS | | |

|COMMISSIONS, BONUSES, ETC. | | |REGULARLY SCHEDULED PRINCIPAL/INT. PMTS. | | |

|PARTNERSHIP DRAWS, ETC. | | |INCOME TAXES (SUM OF A YEAR’S PERIODIC PMTS.) | | |

|PARTNERSHIP DISTRIBUTIONS | | |PARTNERSHIP CONTRIBUTIONS | | |

|INTEREST & DIVIDENDS | | |OTHER TAXES (REAL ESTATE, ETC.) | | |

|RENTAL INCOME | | |LIVING EXPENSES & MISC. | | |

|TRUST DISTRIBUTIONS | | |RENTAL EXPENSES | | |

|OTHER | | |OTHER ANTICIPATED PMTS. (ALIMONY, TUITION) | | |

| | | |OTHER | | |

| | | |TOTAL CASH EXPENSES | | |

|TOTAL CASH INCOME | | |NET CASH FLOW (CASH INCOME – CASH EXPENSES) | | |

* Includes single, divorced, and widowed.

** Income from 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.

*** List all assumptions on page 4 under Additional Comments and describe any significant expected changes in your cash income or your cash expenses.

|SECTION D: CONTINGENT OBLIGATIONS |

| |Instructions: State Total Amount By Type of Liability and Describe; if none, then write none on this section. |

|A. |As Guarantor or Endorser |$ |E. |Letters of Credit |$ |

|B. |On Leases or Contracts |$ |F. |Future Capital Contributions |$ |

|C. |For Legal Claims or Judgments |$ |G. | |$ |

|D. |Income Tax Claim or Dispute |$ |TOTAL A – G |$ |

|DESCRIBE |BENEFICIARY PARTY |AMOUNT OBLIGATED AND WHEN OBLIGATED |PURPOSE OR EXPLANATION |MATURITY OR EXPIRATION DATE |

|(A –G ABOVE) | | | | |

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SCHEDULE 1 – CASH

|1 |ACCOUNT NAME |BANK/BRANCH NAME & ADDRESS |BALANCE |ACCOUNT TYPE |PLEDGED Y OR N? |

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SCHEDULE 2 – MARKETABLE SECURITIES (Stocks, Bonds, Gov’t Issues, Mutual Funds, etc.)

|2 |DESCRIPTION OF SECURITIES |FACE VALUE OR # |CURRENT MARKET VALUE |PLEDGED Y OR N?|MARGIN DEBT |YEARLY DIVIDEND INCOME |

| | |SHARES | | | | |

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|NAME OF BROKERAGE FIRM/BROKER | | | | | |

SCHEDULE 3 – NON-MARKETABLE SECURITIES

|3 |DESCRIPTION OF SECURITIES |FACE VALUE OR # |CURRENT MARKET VALUE |COST |PLEDGED Y OR N? |

| | |SHARES | | | |

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|SCHEDULE 4 – INVESTMENTS IN PARTNERSHIPS |PARTNERSHIP RELATED DEBT | |

|4 |PARTNERSHIP NAME |GENERAL, |% OWNED |COST |CURRENT MARKET VALUE |

| | |LIMITED, OTHER | | | |

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SCHEDULE 7 – OTHER ASSETS

|7 |DESCRIPTION |CURRENT MARKET VALUE |COST |PLEDGED Y OR N? |

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SCHEDULE 8 – NOTES PAYABLE

(exclude mortgage, partnership, and real estate related debt)

|8 |NAME & ADDRESS OF FINANCIAL |PURPOSE |ORIGINAL DATE |ORIGINAL AMOUNT|BALANCE |MATURITY |YEARLY PAY. TERMS |COLLATERAL |

| |INSTITUTION | | | | | | | |

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|In the following statement, the words “I”, “me”, and “my” mean anyone signing below. “You” and “your” refer to Texas Citizens Bank, N.A. |

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|I have given you this financial statement and attachments, if any, in order to obtain credit or services from you. I understand that you will rely on this |

|information in connection with any decision you make in providing credit or services to me. I warrant and represent to you that this financial statement and any |

|other information I may supply to you is correct and fully and accurately discloses all of my assets and liabilities , including, but not limited to, my contingent|

|liabilities, cash income, and cash expenses as of the date I provide this information to you. You may request credit information about me from others including an|

|investigative consumer report and you may request a consumer credit report about me in connection with this financial statement, application for credit or services|

|that I am applying for now and credit or services I may request for in the future for the same or any other purpose. I give you my permission to obtain additional|

|investigative consumer reports and consumer credit reports without telling me to update, renew, extend, or review my credit. I certify I have submitted no |

|“alerts” to any credit bureaus that would create any additional risk to you. I give you my permission to share credit information about me with your affiliates, |

|subsidiaries, parent company, other creditors, and all others permitted or required by law. I authorize you to check my employment history and to answer questions|

|others may ask you about my credit record with you. I understand that I must update this financial statement at your request and if my financial condition |

|changes. You may keep this financial statement whether or not my request for credit or services is approved. I also understand that knowingly providing false or |

|misleading information in this financial statement is a federal offense that may subject me to fine, imprisonment or both (18 USC Section 1014). |

|SIGNATURE |DATE |SIGNATURE |DATE |

|INSURANCE |

|AUTO |HOME/REAL ESTATE |LIFE |

|INSURANCE CO. |INSURANCE CO. |INSURANCE CO. |

|POLICY NO. |POLICY NO. |POLICY NO. |

|COVERAGE |COVERAGE |COVERAGE |

| | |FACE VALUE |

| | |CASH VALUE |

|AGENT NAME |AGENT NAME |AGENT NAME |

|PHONE # |PHONE # |PHONE # |

|NAME OF YOUR PERSONAL ATTORNEY |PERSONAL REFERENCE OR RELATIVE PHONE NUMBER |

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|Are you a defendant in any suits or legal actions? No Yes |

|If Yes, describe under “Additional Comments” area at the bottom of this page. |

|Income tax returns filed through what year? ___________________________________________________ ____ |

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|Are any returns being audited or contested? No Yes |

|If Yes, what year(s) are being audited or contested? |

|Have you drawn a will? No Yes |

|If Yes, year drawn _____________________. Name of your Executor _________________________________________________ |

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|Do you have a line of credit or unused line of credit at any other institution? No Yes |

|If Yes, indicate how much and where: |

|Have you ever filed a petition in bankruptcy or has one been filed involuntarily against you? No Yes |

|If Yes explain in the “Additional Comments” area at the bottom of this page. |

|Are you an Executive Officer, Director, or Principal Shareholder of a bank? No Yes |

|If Yes, Name of Bank: |

ADDITIONAL COMMENTS

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F/S Form Revised April 2014

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