PERSONAL FINANCIAL STATEMENT



PERSONAL FINANCIAL STATEMENT General InformationName FORMTEXT ?????Address FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????Zip FORMTEXT ?????Employer: FORMTEXT ?????Position or Profession: FORMTEXT ?????Employer’s Address: FORMTEXT ?????Partner, officer or owner in any other venture? FORMCHECKBOX No FORMCHECKBOX Yes If so, explain: FORMTEXT ?????Are any assets pledged? FORMCHECKBOX No FORMCHECKBOX Yes (Detail in Schedule A)Income taxes settled through (Date): FORMTEXT ????? Are you a defendant in any suits or legal action? FORMCHECKBOX No FORMCHECKBOX Yes If so, explain: FORMTEXT ?????Have you ever taken bankruptcy? FORMCHECKBOX No FORMCHECKBOX YesIf so, explain: FORMTEXT ?????Do you have a will? FORMCHECKBOX No FORMCHECKBOX Yes With whom? FORMTEXT ?????Do you have a trust? FORMCHECKBOX No FORMCHECKBOX Yes With whom? FORMTEXT ?????Number of dependents: FORMTEXT ?? Ages: FORMTEXT ????? AssetsIn Even DollarsLiabilities and Net WorthIn Even DollarsCash on hand and in Banks - See Schedule A FORMTEXT =ScheduleA 00Notes Payable - See Schedule A FORMTEXT =TotalOwe 00Stocks and Bonds - See Schedule B FORMTEXT =ScheduleB 00Notes Payable - Relatives FORMTEXT ?????Homestead - See Schedule C1 FORMTEXT =MarketValueC1 00Unpaid Taxes FORMTEXT ?????Real Estate Owned - See Schedule C2 FORMTEXT =MarketValueC2 00Credit Card Balances FORMTEXT ?????Accounts/Notes Receivable - See Schedule D FORMTEXT =ScheduleD 00Real Estate Notes Payable - See Schedule C FORMTEXT =SUM(ScheduleC1,ScheduleC2) 00Cash Value Life Insurance - See Schedule E FORMTEXT =ScheduleE 00Other Liabilities: ItemizeRetirement or 401k Plan FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other Assets: (Itemize) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TOTAL LIABILITIES FORMTEXT =SUM(Liab1,Liab2,Liab3,Liab4,Liab5,Liab6,Liab7,Liab8,Liab9) 00 FORMTEXT ????? FORMTEXT ?????NET WORTH FORMTEXT =Assets-Liabilities 00TOTAL ASSETS FORMTEXT =SUM(Asset1,Asset2,Asset3,Asset4,Asset5,Asset6,Asset7,Asset8,Asset9,Asset10,Asset11) 00TOTAL LIABILITIES AND NET WORTH FORMTEXT =NetWorth+Liabilities 00Contingent LiabilitiesIn Even DollarsContingent Liabilities (continued)In Even DollarsAs endorser, co-maker or guarantor FORMTEXT ?????Standby letter of credit FORMTEXT ?????On leases or contracts FORMTEXT ?????Liability in excess of % in partially owned assets FORMTEXT ?????Legal claims or judgments FORMTEXT ?????Tax Liability if assets sold at stated values FORMTEXT ?????Income tax claim or disputed amount FORMTEXT ?????Other FORMTEXT ?????Other special debt (recourse, repurchase liability) FORMTEXT ????? FORMTEXT ?????TOTAL FORMTEXT =SUM(Cont1,Cont2,Cont3,Cont4,Cont5,Cont6,Cont7,Cont8,Cont9,Cont10) 00Schedule A: Banks, Brokers, Savings & Loan Association, Finance Companies or Credit Unions. List the names of all institutions at which you maintain a deposit account and/or where you have loans. Do not include loans secured by real estate (list real estate loans in Schedule C).Name of InstitutionName on AccountBalance on DepositAccount NumberAmount OwingMonthly PaymentSecured by What Assets FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TOTALS FORMTEXT =SUM(Bal1,Bal2,Bal3,Bal4,Bal5,Bal6,Bal7,Bal8,Bal9,Bal10) 00TOTALS FORMTEXT =SUM(Owe1,Owe2,Owe3,Owe4,Owe5,Owe6,Owe7,Owe8,Owe9,Owe10) 00 FORMTEXT =SUM(Pay1,Pay2,Pay3,Pay4,Pay5,Pay6,Pay7,Pay8,Pay9,Pay10) 00Schedule B: U.S. Government Obligations, Stocks (Listed & Unlisted), Bonds (Government & Commercial)Number of SharesName of Stock or BondWhere TradedIn Name ofMarket ValuePledgedYesNo FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX TOTALS FORMTEXT =SUM(Mark1,Mark2,Mark3,Mark4,Mark5,Mark6,Mark7,Mark8,Mark9,Mark10) 00Schedule C1: HomesteadProperty Description or AddressTitle in Name OfYear AcquiredOriginal AmountMarket ValueMortgage or Land Contract PayableBalancePaymentLien Holder FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TOTAL FORMTEXT =OrgAm 00 FORMTEXT =MarketValue 00 FORMTEXT =Bal 00 FORMTEXT =Payment 00Schedule C2: Other Real Estate Owned (and related debt, if applicable)Property Description or AddressTitle in Name OfYear AcquiredOriginal AmountMarket ValueMortgage or Land Contract PayableBalancePaymentLien Holder FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TOTAL FORMTEXT =SUM(OrgAm1,OrgAm2,OrgAm3,OrgAm4,OrgAm5,OrgAm6,OrgAm7,OrgAm8,OrgAm9,OrgAm10) 00 FORMTEXT =SUM(Market1,Market2,Market3,Market4,Market5,Market6,Market7,Market8,Market9,Market10) 00 FORMTEXT =SUM(Balance1,Balance2,Balance3,Balance4,Balance5,Balance6,Balance7,Balance8,Balance9,Balance10) 00 FORMTEXT =SUM(MPay1,MPay2,MPay3,MPay4,MPay5,MPay6,MPay7,MPay8,MPay9,MPay10) 00Schedule D: Accounts and Notes ReceivableDue FromOriginal AmountMaturityPresent BalanceMonthly PaymentRateCollectableCollateralYesNo FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????TOTALS FORMTEXT =SUM(PresBal1,PresBal2,PresBal3,PresBal4,PresBal5,PresBal6) 00 FORMTEXT =SUM(MonPay1,MonPay2,MonPay3,MonPay4,MonPay5,MonPay6) 00Schedule E: Life Insurance & AnnuitiesName of CompanyFace AmountCash ValueLoansNet Cash ValueBeneficiaryInsured FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TOTALS FORMTEXT =SUM(NetValue1,NetValue2,NetValue3,NetValue4) 00This information is provided for the purpose of obtaining credit for the Applicant(s) or for the purpose of Applicant(s) guaranteeing credit for others. Applicant(s) acknowledge that representations made in this statement will be relied on by the Creditor in its decision to grant such credit. This Statement is true and correct in every detail and accurately represents the financial condition of the Applicant(s) on the date given below. Creditor is authorized to make all inquiries it deems necessary to verify the accuracy of the information contained herein and to determine the creditworthiness of the Applicant(s). Applicant(s) will promptly notify Creditor of any subsequent changes which would affect the accuracy of this Statement. Creditor is further authorized to answer any questions about Creditor’s credit experience with Applicant(s). Applicant(s) are aware that any knowing or willful false statements regarding the value of the above property for purposes of influencing the actions of creditor can be a violation of federal law, 18 U.S.C. &1014, and may result in a fine or imprisonment or both.In addition, each individual signing below authorizes the Creditor to check their individual credit account and employment history and have a credit reporting agency prepare a consumer credit report on them.This statement is accurate as of FORMTEXT ?????___. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Applicant’s SignatureDate SignedSocial Security NumberDate of Birth FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Co -Applicant’s SignatureDate SignedSocial Security NumberDate of BirthPERSONAL CASH FLOW STATEMENTName(s): FORMTEXT ?????Date: FORMTEXT ?????Monthly IncomeGross Salary FORMTEXT ?????Bonuses FORMTEXT ?????Dividends FORMTEXT ?????Interest FORMTEXT ?????Net Rental Income FORMTEXT ?????Other Business Income FORMTEXT ?????Note Receivable FORMTEXT ?????Other (Itemize) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Total Income FORMTEXT =sum(GrossSalary,Bonus,Dividends,Interest,Rental,OtherBus,NoteRec,Other1,Other2,Other3) 00Monthly ExpensesRent/Mortgage Payment FORMTEXT ?????Auto Loan(s) FORMTEXT ?????Other Notes Payable FORMTEXT ?????Credit Card Payment(s) FORMTEXT ?????Income Taxes FORMTEXT ?????Utilities FORMTEXT ?????Living Expenses FORMTEXT ?????Other (Itemize) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Total Expenses FORMTEXT =sum(RentMtgPay,AutoLoan,OtherNotePay,CCPay,IncomeTaxes,Utilities,LivingExp,OtherExp1,OtherExp2,OtherExp3,OtherExp4) 00Net Cash Flow FORMTEXT =TlIncome-TlExp 00(Income less Expenses)SignatureDateSignatureDate ................
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