CERTIFICATION OF FINANCIAL STATEMENT



CERTIFICATION OF FINANCIAL INFORMATION

Borrower(s):      

Address:      

     

Tax I.D. or Social Security Number:      

Individual Partnership Corporation LLC Other

To: First Community Bank

|Financial Information Provided |

|Personal Financial Statement Dated:       |

|Business Financial Statement for Periods Ending:       |

|Income Tax Returns for Years Ending:       |

|Other Financial Documents:      |

Loan Number      

The above information is submitted to support my application for credit.

I/we are applying for credit as of:      

Regulation B requires a lender to obtain the applicant’s intent to apply for joint credit or to become liable as a guarantor on the debt. Please select one of the following three options:

I am applying for individual credit or to act as individual guarantor for the indebtedness of another party.

I/We are applying for joint credit (all parties must sign below).

I/We intend to act as joint guarantors for the indebtedness of another party (all parties must sign below).

The attached financial information listed above is the most recent financial information prepared by or for me. I understand that First Community Bank is relying on the information in this financial statement, tax return, or other financial document in deciding to give or continue the financial accommodation or extension of credit requested or received. These statements are delivered to First Community Bank to induce it to extend credit from time to time and/or to continue its present extensions of credit, at its discretion, to the undersigned. The undersigned hereby certifies that these statements are correct and complete, and accurately reflect the condition and affairs of the undersigned at the date and for the period(s) stated and that said statements reflect all known liabilities, direct or contingent, as of the date thereof.

The undersigned also represents and warrants that to his/her knowledge there has to date been no material adverse change in the condition or affairs of undersigned from the date of said statements.

The undersigned does hereby represent and warrant that legal title to all property herein described or referred to, excepting only jointly owned property as separately scheduled herein as such, is in the sole name of the undersigned. Every individual whom is a party to this statement agrees that his/her separate property listed herein or herein referred to and property or interests in property owned jointly, by entirety or in common with another party to this statement has been accurately and proportionately represented.

First Community Bank is authorized to make all inquiries deemed necessary to verify the accuracy of the information continued herein, and to determine the creditworthiness of the undersigned. Each of the undersigned authorizes the Bank to answer questions about its credit experience with the undersigned.

Right to Receive Copy of Appraisal

NOTICE: If the collateral which will secure this loan in whole or in part is a 1st lien on a 1-4 family residence, this notice applies to your application for credit.

We may order an appraisal to determine the property’s value and charge you for this appraisal. We will promptly give you a copy of any appraisal, even if your loan does not close. You can pay for an additional appraisal for your own use at your own cost.

Equal Credit Opportunity Notice

Were your gross annual revenues in the previous fiscal year $1,000,000.00 or more? Yes No

If you answered yes and your application is denied, you have the right to receive a written statement of the specific reasons for this denial. To obtain the statement, please contact the Bank as noted below within 60 days from the date you were notified of our decision:

First Community Bank, Attn: Compliance Officer, 200 East Main St., Harbor Springs, MI 49740; (231)526-2114

We will send you a written statement of reasons for the denial within 30 days of receiving your request. The notice below describes additional protections extended to you.

NOTICE: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (providing the applicant has the capacity to enter into a binding contract); because all or a part of the applicant’s income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning this creditor is:

Federal Reserve Consumer Help Center, P.O. Box 1200, Minneapolis, MN 55480

I HAVE READ, UNDERSTAND AND AGREE TO MAKE THESE REPRESENTATIONS AND WARRANTIES.

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|Signature: |Signature: |

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|Name:       |Name:       |

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|Social Security Number: xxx-xx-      |Social Security Number: xxx-xx-       |

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|Date of Birth:       |Date of Birth:       |

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|Signature: |Signature: |

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|Name:       |Name:       |

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|Social Security Number: xxx-xx-      |Social Security Number: xxx-xx-       |

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|Date of Birth:       |Date of Birth:       |

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|Signature: |Signature: |

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|Name:      |Name:       |

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|Social Security Number: xxx-xx-      |Social Security Number: xxx-xx-       |

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|Date of Birth:       |Date of Birth:       |

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