Personal Financial Statement

Please fill in the form below and click SUBMIT FORM.

Name in Full

Email Address

Telephone

Age

Employer

Yrs at address

Address (No. & Street)

City & State

Residence Address (No. & Street, City, State, Zip code)

Previous Address if at above address less than 5 yrs:(No. & Street, City, State, Zip code)

Dependents

Ages

Number

CO-BORROWER INFORMATION

Co-Borrower

Social Security No

Age

Telephone

Employer

Address (No. & Street)

City & State

FINANCIAL CONDITION AS OF DATE

Are any of the assets listed on this statement held under a trust agreement?

Yes - Give Details:

Have you ever filed any petition under the Bankruptcy Act?

Give details of any contingent liability as endorser or guarantor, or on suits or judgements pending:

Assets

CASH

Bank

Office

Amount

Other Banks:

Amount

Other

Amount

STOCKS AND BONDS

Listed (from schedule 1 below)

Unlisted (from schedule 1 below)

REAL ESTATE

Improved (from schedule 2 below)

Unimproved (from schedule 2 below)

Trust deeds and mortgages (from schedule 3 below)

Trust Deeds Amount

LIFE INSURANCE

LIFE INSURANCE

ACCOUNTS AND NOTES RECEIVABLE

Relatives and Friends (from schedule 4 below)

Collectible (from schedule 4 below)

Doubtful (from schedule 4 below)

Other

OTHER PERSONAL PROPERTY

Automobile

Other (itemize, schedule 4)

TOTAL

LIABILITIES

NOTES PAYABLETO BANKS

Bank:

Office:

Amount

Other Banks (from schedule 4 below)

Other

OTHER NOTES AND ACCOUNTS PAYABLE

Real Estate Loans (from schedule 2 below)

Real Estate Loans (from schedule 2 below): Unlisted (from schedule 1 below): Sales contracts & Sec. Agreements (from schedule 4 below)

Loans on life insurance policies (schedule 4 below)

Other

TAXES PAYABLE

Current year's income taxes unpaid

Prior years' income taxes unpaid

Real estate taxes unpaid

Other

OTHER LIABILITIES

Unpaid Interest

Others (from schedule 4 below)

TOTAL LIABILITIES

NET WORTH:

TOTAL

ANNUAL INCOME

SALARY OR WAGES:

DIVIDENDS AND INTEREST:

RENTALS (GROSS)

BUSINESS OR PROFESSIONAL INCOME (NET):

OTHER INCOME:

ANNUAL EXPENDITURES

PROPERTY TAXES AND ASSESSMENTS:

FEDERAL AND STATE INCOME TAXES:

REAL ESTATE LOAN PAYMENTS:

INSURANCE PREMIUMS:

PAYMENTS ON CONTRACTS AND OTHER NOTES:

ESTIMATED LIVING EXPENSES:

OTHER: (Alimony, Child Support, Maintenance):

TOTAL INCOME:

TOTAL EXPENDITURES:

LIFE INSURANCE

FACE AMOUNT

BENEFICIARY

COMPANY

SCHEDULE 1: LISTED AND UNLISTED STOCKS AND BONDS OWNED

LISTED

No. of shares or par value

Description:

Issued in name of:

Joint tennancy (JT) Ten. in common (TC) Comm. Property (CP)

Market Value

UNLISTED

No. of shares or par value

Description:

Issued in name of:

Joint tennancy (JT) Ten. in common (TC) Comm. Property (CP)

Market Value

SCHEDULE 2: REAL ESTATE OWNED (Designate: I - Improved, U - Unimproved)

Location or description:

I/U

Title in name of:

Joint tennancy (JT) Ten. in common (TC) Comm. Property (CP)

Cost

Present value

Trust Deeds, Mortgages, or other Leins

Unpaid Balance:

Rate %

Monthly Payment

Held By

Cost

Present value

Total

SCHEDULE 3: TRUST DEEDS AND MORTGAGES OWNED:

Name of Payer

Legal Desc, Street Address, & Type of Improvements

Unpaid Balance

Joint tennancy (JT) Ten. in common (TC) Comm. Property (CP)

Terms

1st or 2nd Lien

Value of property:

TOTAL

Unpaid Balance

Value of property:

SCHEDULE 4: DETAILS RELATIVE TO OTHER IMPORTANT ASSETS AND LIABILITIES

I hereby certify that I have carefully filled out the above, and it is complete, true, and correct statement to the best of my knowledge and belief (enter name):

Date:

Signature

Sign Here

Personal Financial Statement