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)
