PERSONAL FINANCIAL STATEMENT

 

Date:  ______________________

Submitted To:  _______________

 

PERSONAL INFORMATION

Name of Applicant ____________________________________________________

 

Employer ____________________________________________________________

 

Address of Employer ___________________________________________________

 

Business Phone Number _________________________________________________

 

No. of Years with Employer ______________________________________________

 

Title/Position _________________________________________________________

 

Name of Previous Employer & Position (if with current employer less than 3 years) ___________________________________________________________________

 

No. of Years with Previous Employer_________________________________

 

Home Address _______________________________________________________

 

Home Phone ________________________________________________________

 

Social Security No. ___________________________________________________

 

Date of Birth ________________________________________________________

Name, Phone No. of Your Accountant _____________________________________

 

Name, Phone No. of Your Attorney _______________________________________

 

Name, Phone No. of Your Investment Advisor/Broker _________________________

 

Name, Phone No. of Your Insurance Advisor ________________________________

 

Name of Co-Applicant __________________________________________________

 

Employer ____________________________________________________________

 

Address of Employer ___________________________________________________

 

Business Phone Number _________________________________________________

 

No. of Years with Employer ______________________________________________

 

Title/Position __________________________________________________________

 

Name of Previous Employer & Position (if with current employer less than 3 years) ___________________________________________________________________

 

No. of Years with Previous Employer_________________________________

 

Home Address ________________________________________________________

 

Home Phone __________________________________________________________

 

Social Security No. _____________________________________________________

Date of Birth __________________________________________________________

 

Name, Phone No. of Your Accountant _______________________________________

 

Name, Phone No. of Your Attorney _________________________________________

 

Name, Phone No. of Your Investment Advisor/Broker __________________________

 

Name, Phone No. of Your Insurance Advisor _________________________________

 

CASH INCOME & EXPENDITURES STATEMENT

FOR YEAR ENDED ____________ (OMIT CENTS)

 

ANNUAL INCOME                                                                                                   AMOUNT ($)

Salary (applicant) _________________________________                     ___________

 

Salary (co-applicant) _______________________________                         ___________

 

Bonuses & Commissions (applicant) ___________________                         ___________

 

Bonuses & Commissions (co-applicant) _________________                   __________

 

Rental Income ____________________________________                    ___________

 

Interest Income ___________________________________                         ___________

 

Dividend Income __________________________________                    ___________

 

Capital Gains ____________________________________                          ___________

 

Partnership Income ________________________________                        ___________

 

Other Investment Income ___________________________                    ___________

 

Other Income (list)  ________________________________                         ___________

                                            ________________________________                ___________

 

                                                                                                                     Total Income   $___________

 

Any significant changes expected in the next 12 months?  [ ] Yes [ ] No

(If yes, attach information.)

 

** Income from alimony, child support, or separate maintenance income need not be revealed if the applicant or co-applicant does not wish to have it considered as a basis for repaying this obligation.

 

ANNUAL EXPENDITURES                                                                    AMOUNT ($)

Federal Income and Other Taxes _____________________                 ___________

 

State Income and Other Taxes _______________________                                ___________

 

Rental Payments, Co-op, or Condo Maintenance _________

            ____________________________________________                         ___________

 

Mortgage Payments (Residential) _____________________                               ___________

                                        (Investment) _____________________                     ___________

 

Property Taxes (Residential) _________________________                               ___________

                                (Investment) _________________________                     ___________

 

Interests & Principal Payments on Loans _______________                      ___________

 

Insurance ________________________________________                            ___________

 

Investments (Including tax shelters) ___________________                      ___________

 

Alimony/Child Support _____________________________                              ___________

 

Tuition __________________________________________                            ___________

 

Other Living Expenses ______________________________                     ___________

 

Medical Expenses _________________________________                                ___________

 

Other Expenses (list) _______________________________                                ___________

                                             _______________________________                     ___________

 

                                                                                   Total Expenditures                      $___________

 

Balance Sheet as of ____________

 

ASSETS                                                                                                                                         AMOUNT ($)

Cash in this Bank _______________________________                                      ___________

            (Including money market accounts, CDs)

 

Cash in Other Financial Institutions (list) ____________

            _________________________________________                                                  ___________

            (Including money market accounts, CDs)

 

Readily Marketable Securities (Schedule A)____________                        ___________

 

Non-Readily Marketable Securities (Schedule A) ________                       ___________

 

Accounts and Notes Receivable _____________________                       ____________

 

Net Cash Surrender Value of Life Insurance (Schedule B)                           __________

 

Residential Real Estate (Schedule C) _________________                        ___________

 

Real Estate Investments (Schedule C) ________________                         ___________

 

Partnerships / PC Interests (Schedule D) ______________                        ___________

 

IRA, Keogh, Profit-sharing & Other Vested Retirement

Accounts ______________________________________                                 ___________

 

Personal Property (including automobiles) ____________                    ___________

 

Other Assets (list):  ______________________________                                  ___________

                                       ______________________________                                               ___________

 

                                                                                                                                              Total  $__________

 

LIABILITIES                                                                                              AMOUNT ($)

Notes Payable to this Bank ________________________                                   ___________

            Secured _________________________________                                    ___________

            Unsecured _______________________________                                   ___________

 

Notes Payable to Others (E) _______________________                                    ___________

            Secured _________________________________                                    ___________

            Unsecured _______________________________                                   ___________

 

Accounts Payable (including credit cards) ____________                                    ___________

 

Margin Accounts _______________________________                                   ___________

 

Notes Due: Partnership (Schedule D) _______________                                       ___________

 

Taxes Payable _________________________________                                     ___________

 

Mortgage Debt (Schedule C) ______________________                                     ___________

 

Life Insurance Loans (Schedule B) _________________                                      ___________

 

Other Liabilities (list): __________________________                                        ___________

                                              __________________________                                 ___________

 

                                                                                                                       Total Liabilities $__________

                                                                                                                                  Net Worth $__________

                                                                                                                                                            $__________

 

CONTINGENT LIABILITIES

Are you a guarantor, comaker, or endorser for any debt of an individual, corporation, or partnership?  [ ] Yes [ ] No   $__________

 

Do you have any outstanding letters of credit or surety bond?  [ ] Yes [ ] No   $_______

 

Are there any suits or legal actions pending against you?      [ ] Yes [ ] No   $__________

 

Are you contingently liable on any lease or contract?               [ ] Yes [ ] No   $__________

Are any of your tax obligations past due?                                  [ ] Yes [ ] No   $__________

 

What would be your total estimated tax liability if you were to sell your major assets?

                                                                                                                                                        $__________

If yes for any of the above, give details:

 

SCHEDULE A - ALL SECURITIES (including non-money market mutual funds)

 

Readily Marketable Securities (including U.S. Governments and Municipalities)*

No. of Shares or Face Value _____________________________________________

 

Description __________________________________________________________

 

Owner(s) ____________________________________________________________

 

Where Held __________________________________________________________

 

Cost ________________________________________________________________

 

Current Market Value __________________________________________________

Pledged [ ] Yes [ ] No

 

No. of Shares or Face Value ______________________________________________

Description ___________________________________________________________

 

Owner(s) ____________________________________________________________

 

Where Held __________________________________________________________

 

Cost ________________________________________________________________

Current Market Value ___________________________________________________

Pledged [ ] Yes [ ] No

 

No. of Shares or Face Value _____________________________________________

 

Description ___________________________________________________________

 

Owner(s) ____________________________________________________________

 

Where Held __________________________________________________________

 

Cost ________________________________________________________________

 

Current Market Value ___________________________________________________

Pledged [ ] Yes [ ] No

* If not enough space, attach a separate schedule or brokerage statement and enter totals only.

 

Non-Readily Marketable Securities (closely held, or restricted stock)

No. of Shares or Face Value _____________________________________________

 

Description ___________________________________________________________

 

Owner(s) ____________________________________________________________

 

Where Held __________________________________________________________

 

Cost ________________________________________________________________

Current Market Value ___________________________________________________

Pledged [ ] Yes [ ] No

No. of Shares or Face Value ______________________________________________

 

Description ___________________________________________________________

 

Owner(s) ____________________________________________________________

 

Where Held __________________________________________________________

 

Cost ________________________________________________________________

 

Current Market Value ___________________________________________________

Pledged [ ] Yes [ ] No

 

SCHEDULE B - INSURANCE

Life Insurance (use additional sheet if necessary)

Insurance Company ___________________________________________________

 

Face Amount of Policy _________________________________________________

 

Type of Policy _______________________________________________________

 

Beneficiary ___________________________________________________________

 

Cash Surrender Value ___________________________________________________

 

Amount Borrowed _____________________________________________________

 

Ownership ___________________________________________________________

 

Insurance Company ___________________________________________________

Face Amount of Policy _________________________________________________

 

Type of Policy _______________________________________________________

 

Beneficiary ___________________________________________________________

 

Cash Surrender Value ___________________________________________________

 

Amount Borrowed _____________________________________________________

 

Ownership ___________________________________________________________

 

Insurance Company ___________________________________________________

 

Face Amount of Policy _________________________________________________

 

Type of Policy _______________________________________________________

 

Beneficiary ___________________________________________________________

 

Cash Surrender Value ___________________________________________________

 

Amount Borrowed ____________________________________________________

 

Ownership ___________________________________________________________

 

 

Disability Insurance                                                                        Applicant                              Co-Applicant

Monthly distribution if disabled                                   ________                             ___________

Number of Years covered                                                               ________                             ___________

SCHEDULE C - PERSONAL RESIDENCE & REAL ESTATE INVESTMENTS, MORTGAGE DEBT (majority ownership only)

Personal Residence:

Property Address ______________________________________________________

 

Legal Owner __________________________________________________________

 

Purchase Year/Price ____________________________________________________

 

Market Value _________________________________________________________

 

Present Loan Balance ___________________________________________________

 

Interest Rate __________________________________________________________

 

Monthly Payment ______________________________________________________

 

Lender ______________________________________________________________

Personal Residence:

Property Address ______________________________________________________

 

Legal Owner __________________________________________________________

 

Purchase Year/Price ____________________________________________________

 

Market Value _________________________________________________________

 

Present Loan Balance ___________________________________________________

 

Interest Rate __________________________________________________________

Monthly Payment ______________________________________________________

 

   Lender ______________________________________________________________

Real Estate Investment:

Property Address ______________________________________________________

 

Legal Owner __________________________________________________________

 

Purchase Year/Price _____________________________________________________

 

Market Value __________________________________________________________

 

Present Loan Balance ____________________________________________________

 

Interest Rate ___________________________________________________________

 

Monthly Payment _______________________________________________________

 

Lender _______________________________________________________________

Real Estate Investment:

Property Address ______________________________________________________

 

Legal Owner __________________________________________________________

 

Purchase Year/Price _____________________________________________________

 

Market Value __________________________________________________________

 

Present Loan Balance ____________________________________________________

 

Interest Rate __________________________________________________________

 

Monthly Payment _______________________________________________________

 

Lender ______________________________________________________________

 

SCHEDULE D - PARTNERSHIPS (LESS THAN MAJORITY OWNERSHIP

                            FOR REAL ESTATE PARTNERSHIPS)*

Business/Professional (indicate name):

Type of Investment ____________________________________________________

 

Date of Initial Investment ________________________________________________

 

Cost _______________________________________________________________

 

Percent Owned _______________________________________________________

 

Current Market Value __________________________________________________

 

Balance Due on Partnerships:  Notes, Cash Call _______________________________

____________________________________________________________________

 

Final Contribution Date _________________________________________________

Business/Professional (indicate name):

Type of Investment ____________________________________________________

 

Date of Initial Investment _______________________________________________

 

Cost _______________________________________________________________

 

Percent Owned _______________________________________________________

 

Current Market Value __________________________________________________

 

Balance Due on Partnerships:  Notes, Cash Call _______________________________

___________________________________________________________________

 

Final Contribution Date _________________________________________________

*Note:  For investments which represent a material portion of your total assets, please include the relevant financial statements or tax returns, or in the case of partnership investments or S-corporations, schedule K-1s.

 

SCHEDULE E - NOTES PAYABLE

Due to ______________________________________________________________

 

Type of Facility _______________________________________________________

 

Amount of Line _______________________________________________________

Secured [ ] Yes [ ] No

 

Collateral ____________________________________________________________

 

Interest Rate __________________________________________________________

 

Maturity _____________________________________________________________

 

Unpaid Balance _______________________________________________________

 

Due to ______________________________________________________________

 

Type of Facility _______________________________________________________

 

Amount of Line _______________________________________________________

Secured [ ] Yes [ ] No

 

Collateral ____________________________________________________________

 

Interest Rate __________________________________________________________

 

Maturity _____________________________________________________________

 

    Unpaid Balance _______________________________________________________

 

PLEASE ANSWER THE FOLLOWING QUESTIONS:

1.  Income tax returns filed through _______________ (date).  Are any returns currently being audited or contested?  [ ] Yes [ ] No

If yes, what year(s):  ______________________________________________

 

2.  Have (either of) you or any firm in which you were a major owner ever declared

bankruptcy?  [ ] Yes [ ] No 

If yes, please provide detail:  ____________________________________________

 

3.  Have you drawn a will?  [ ] Yes [ ] No

If yes, please furnish the name of the executor(s) and year will was drawn: ___________________________________________________________________

 

4.  Number of dependents (excluding self) and relationship to applicant: ____________________________________________________________________

 

5.  Have you ever had a financial plan prepared for you?  [ ] Yes [ ] No

6.  Did you include two years federal and state tax returns?  [ ] Yes [ ] No

 

7.  Do (either of) you have a line of credit or unused credit facility at any other

institution(s)?  [ ] Yes [ ] No

If so, please indicate where, how much, and name of banker:  ____________________

___________________________________________________________________

___________________________________________________________________

 

8.  Do you anticipate any substantial inheritances?  [ ] Yes [ ] No

If yes, please explain:  ___________________________________________________

____________________________________________________________________

 

 

REPRESENTATIONS AND WARRANTIES

 

The information contained in the statement is provided to induce you to extend or to continue the extension of credit to the undersigned or to others upon the guarantee of the undersigned.  The undersigned acknowledge and understand that you are relying on the information provided herein in deciding to grant or continue credit or to accept a guarantee thereof.  Each of the undersigned represents, warrants and certifies that the information provided herein is true, correct, and complete.  Each of the undersigned agrees to notify you immediately and in writing of any change in name, address, or employment and of any material adverse change (1) in any of the information contained in this statement (2) in the financial condition of any of the undersigned or (3) in the ability of any of the undersigned to perform its (or their) obligations to you.  In the absence of such notice or a new and full written statement, this should be considered as a continuing statement and substantially correct.  If the undersigned fail to notify you as required above, or if any of the information herein should prove to be inaccurate or incomplete in any material aspect, you may declare the indebtedness of the undersigned or the indebtedness guaranteed by the undersigned, as the case may be, immediately due and payable.  You are authorized to make all inquiries you deem necessary to verify the accuracy of the information contained herein and to determine the creditworthiness of the undersigned.  The undersigned authorizes any person or consumer reporting agency to give you any information it may have on the undersigned.  Each of the undersigned authorizes you to answer questions about your credit experience with the undersigned.  As long as any obligation or guarantee of the undersigned to you is outstanding , the undersigned shall supply annually an updated financial statement.  This personal financial statement and any other financial or other information that the undersigned gives you shall be your property.

 

 

_____________________                           _____________________________________

Date                                                                    Your Signature

 

_____________________                           _____________________________________

Date                                                                    Co-Applicants Signature (if you are requesting

                                                                            the financial accommodation jointly)