Personal Financial Statement

Date of Financial Statement*

Name*

First Name

Last Name

Date of Birth*

Social Security Number*

Email

Home Phone

Cell Phone

Present Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Residence:

Own Rent Other

Mortgage Payment or Rent Per Month $

Explain Other Residence

Employer's Name*

Employer's Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Title/Position*

Length of Employment*

Years and Months

Business Phone Number

Do you have a Spouse?*

Yes No

If married, you may apply for a separate account. If you are married, complete all information for yourself and your spouse. You do not have to list spouse's separate property unless this is an application for a joint account. Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.

Spouse's Information

Name

First Name

Last Name

Date of Birth

Social Security Number

Number of Dependents

Employer's Name

First Name

Last Name

Employer's Address

Address Line 1

Address Line 2

City

State

ZIP Code

Title/Position

Length of Employment

Years and Months

Business Phone Number

Are you applying for a joint account?*

Yes No

List of Assets

Cash in The Bank $

List Cash in Other Institutions

Bank or Credit Union Name

Amount $

Bank or Credit Union Name (2)

Amount (2) $

Bank or Credit Union Name (3)

Amount (3) $

Bank or Credit Union Name (4)

Amount (4) $

List of Assets

Stocks and Bonds Owned Amount (Schedule 1) $

IRA/Keogh/Pension Amounts $

Accounts/Notes Receivable Amount (Schedule 2) $

Deeds of Trusts Owned Amount (Schedule 2) $

Real Estate Market Value(s) (Schedule 3) $

Other Investments/Partnerships Amount $

Automobiles Owned

Make and year.

Automobiles Value $

Personal Property Amount $

Other Assets Amount $

Attach detail.

Total Assets $

Liabilities

Income Taxes Payable (Amount Owed) $

Income Taxes Payable (Monthly Payment) $

Other Taxes Payable (Amount Owed) $

Other Taxes Payable (Monthly Payment) $

Charge Cards Payable (Schedule 4) (Amount Owed) $

Charge Cards Payable (Schedule 4) (Monthly Payment) $

Installment Loans (Schedule 4) (Amount Owed) $

Installment Loans (Schedule 4) (Monthly Payment) $

Loans on Life Insurance (Amount Owed) $

Loans on Life Insurance (Monthly Payment) $

Real Estate Indebtedness (Schedule 3) (Amount Owed) $

Real Estate Indebtedness (Schedule 3) (Monthly Payment) $

Loans on Stocks & Bonds

Name of Company

Amount Owed $

Monthly Payment $

Name of Company (2)

Amount Owed (2) $

Monthly Payment (2) $

Name of Company (3)

Amount Owed (3) $

Monthly Payment (3) $

Name of Company (4)

Amount Owed (4) $

Monthly Payment (4) $

List Other Liabilities

Liability

Amount Owed $

Monthly Payment $

Liability (2)

Amount Owed (2) $

Monthly Payment (2) $

Totals

Total Amount Owed $

Total Monthly Payments $

Net Worth (Assets - Liabilities) $

Total Liabilities + Net Worth $

Annual Income

Applicant Salary $

Dividend / Bond Income $

Interest Income $

Rental Income $

Spouse's Salary $

Other Income

Other Income Detail (1)

Other Income Amount (1) $

Other Income Detail (2)

Other Income Amount (2) $

Other Income Detail (3)

Other Income Amount (3) $

Other Income Detail (4)

Other Income Amount (4) $

Other Income Detail (5)

Other Income Amount (5) $

Total

Total Annual Income $

Annual Expenses

Interest Expense $

Property Taxes $

Income & Other Taxes $

Mortgage Payments/Rent $

Credit Card Payments $

Loan Payments $

Insurance $

Alimony, Child Support $

Other Expenses

Other Expense Detail (1)

Other Expense Amount (1) $

Other Expense Detail (2)

Other Expense Amount (2) $

Total

Total Expenses $

Contingent Liabilities

As an Endorser $

As a Guarantor $

As a Co-signer $

On Damage Claims $

Letters of Credit $

Other Contingent Liabilities

Other Contingent Liability Detail (1)

Other Contingent Liability Amount (1) $

Other Contingent Liability Detail (2)

Other Contingent Liability Amount (2) $

Other Contingent Liability Detail (3)

Other Contingent Liability Amount Amount (3) $

Other Contingent Liability Detail (4)

Other Contingent Liability Amount (4) $

Other Contingent Liability Detail (5)

Other Contingent Liability Amount (5) $

Total

Total Contingent Liabilities $

Schedule 1: Marketable Securities

Are any of your Securities Restricted?

Yes No

Do you own 10% or more of the outstanding stock of any company?

Yes No

How Held

Joint with spouse Applicant's separate property Joint with other than spouse Spouse's separate property

Number of Shares or Bond Amount

Description

Title In Name Of

Pledged

Present Market Value $

Add another to list?

Yes No

How is it held (2):

Joint with spouse Applicant's separate property Joint with other than spouse Spouse's separate property

Number of Shares or Bond Amount (2)

Description (2)

Title In Name Of (2)

Pledged (2)

Present Market Value (2) $

Add another to list?

Yes No

How is it held (3):

Joint with spouse Applicant's separate property Joint with other than spouse Spouse's separate property

Number of Shares or Bond Amount (3)

Description (3)

Title In Name Of (3)

Pledged (3)

Present Market Value (3) $

Add another to list?

Yes No

How is it held (4):

Joint with spouse Applicant's separate property Joint with other than spouse Spouse's separate property

Number of Shares or Bond Amount (4)

Description (4)

Title In Name Of (4)

Pledged (4)

Present Market Value (4) $

Total Marketable Securities $

Schedule 2: Notes Receivable - Mortgage & Deed of Trust Owned

How is it held:

Joint with spouse Applicant's separate property Joint with other than spouse Spouse's separate property

Name of Debtor

Collateral

Date of Note

Monthly Payment $

Maturity Date

Unpaid Balance $

Add another to list?

Yes No

How is it held (2):

Joint with spouse Applicant's separate property Joint with other than spouse Spouse's separate property

Name of Debtor (2)

Collateral (2)

Date of Note (2)

Monthly Payment (2) $

Maturity Date (2)

Unpaid Balance (2) $

Total Unpaid Balance $

Schedule 3: Real Estate Holdings - Mortgages or Liens

How is it held:

Joint with spouse Applicant's separate property Joint with other than spouse Spouse's separate property

Type:

Single Dwelling Multiple Dwelling Commercial/Industrial

Property Address

Address Line 1

Address Line 2

City

State

ZIP Code

Market Value $

Original Cost $

Date Purchased

% Owned

Lender Name

Balance $

Monthly Payment $

If you have a second mortgage on this property:

Second Lender Name

Second Balance $

Second Monthly Payment $

Add a second property?

Yes No

Property #2

How is it held:

Joint with spouse Applicant's separate property Joint with other than spouse Spouse's separate property

Type:

Single Dwelling Multiple Dwelling Commercial/Industrial

Property Address

Address Line 1

Address Line 2

City

State

ZIP Code

Market Value $

Original Cost $

Date Purchased

% Owned

Lender Name

Balance $

Monthly Payment $

If you have a second mortgage on this property:

Second Lender Name

Second Balance $

Second Monthly Payment $

Add a third property?

Yes No

Property #3

How is it held:

Joint with spouse Applicant's separate property Joint with other than spouse Spouse's separate property

Type:

Single Dwelling Multiple Dwelling Commercial/Industrial

Property Address

Address Line 1

Address Line 2

City

State

ZIP Code

Market Value $

Original Cost $

Date Purchased

% Owned

Lender Name

Balance $

Monthly Payment $

If you have a second mortgage on this property:

Second Lender Name

Second Balance $

Second Monthly Payment $

Add a fourth property?

Yes No

Property #4

How is it held:

Joint with spouse Applicant's separate property Joint with other than spouse Spouse's separate property

Type:

Single Dwelling Multiple Dwelling Commercial/Industrial

Property Address

Address Line 1

Address Line 2

City

State

ZIP Code

Market Value $

Original Cost $

Date Purchased

% Owned

Lender Name

Balance $

Monthly Payment $

If you have a second mortgage on this property:

Second Lender Name

Second Balance $

Second Monthly Payment $

Add a fifth property?

Yes No

Property #5

How is it held:

Joint with spouse Applicant's separate property Joint with other than spouse Spouse's separate property

Type:

Single Dwelling Multiple Dwelling Commercial/Industrial

Property Address

Address Line 1

Address Line 2

City

State

ZIP Code

Market Value $

Original Cost $

Date Purchased

% Owned

Lender Name

Balance $

Monthly Payment $

If you have a second mortgage on this property:

Second Lender Name

Second Balance $

Second Monthly Payment $

Add a sixth property?

Yes No

Property #6

How is it held:

Joint with spouse Applicant's separate property Joint with other than spouse Spouse's separate property

Type:

Single Dwelling Multiple Dwelling Commercial/Industrial

Property Address

Address Line 1

Address Line 2

City

State

ZIP Code

Market Value $

Original Cost $

Date Purchased

% Owned

Lender Name

Balance $

Monthly Payment $

If you have a second mortgage on this property:

Second Lender Name

Second Balance $

Second Monthly Payment $

Add a seventh property?

Yes No

Property #7

How is it held:

Joint with spouse Applicant's separate property Joint with other than spouse Spouse's separate property

Type:

Single Dwelling Multiple Dwelling Commercial/Industrial

Property Address

Address Line 1

Address Line 2

City

State

ZIP Code

Market Value $

Original Cost $

Date Purchased

% Owned

Lender Name

Balance $

Monthly Payment $

If you have a second mortgage on this property:

Second Lender Name

Second Balance $

Second Monthly Payment $

Add an eighth property?

Yes No

Property #8

How is it held:

Joint with spouse Applicant's separate property Joint with other than spouse Spouse's separate property

Type:

Single Dwelling Multiple Dwelling Commercial/Industrial

Property Address

Address Line 1

Address Line 2

City

State

ZIP Code

Market Value $

Original Cost $

Date Purchased

% Owned

Lender Name

Balance $

Monthly Payment $

If you have a second mortgage on this property:

Second Lender Name

Second Balance $

Second Monthly Payment $

Add a ninth property?

Yes No

Property #9

How is it held:

Joint with spouse Applicant's separate property Joint with other than spouse Spouse's separate property

Type:

Single Dwelling Multiple Dwelling Commercial/Industrial

Property Address

Address Line 1

Address Line 2

City

State

ZIP Code

Market Value $

Original Cost $

Date Purchased

% Owned

Lender Name

Balance $

Monthly Payment $

If you have a second mortgage on this property:

Second Lender Name

Second Balance $

Second Monthly Payment $

Add a tenth property?

Yes No

Property #10

How is it held:

Joint with spouse Applicant's separate property Joint with other than spouse Spouse's separate property

Type:

Single Dwelling Multiple Dwelling Commercial/Industrial

Property Address

Address Line 1

Address Line 2

City

State

ZIP Code

Market Value $

Original Cost $

Date Purchased

% Owned

Lender Name

Balance $

Monthly Payment $

If you have a second mortgage on this property:

Second Lender Name

Second Balance $

Second Monthly Payment $

Total Owed $

Total Payments $

Schedule 4: Credit Cards And Loans Payable

Name of Creditor

Monthly Payment $

Current Balance $

Name of Creditor (2)

Monthly Payment (2) $

Current Balance (2) $

Name of Creditor (3)

Monthly Payment (3) $

Current Balance (3) $

Name of Creditor (4)

Monthly Payment (4) $

Current Balance (4) $

Name of Creditor (5)

Monthly Payment (5) $

Current Balance (5) $

Name of Creditor (6)

Monthly Payment (6) $

Current Balance (6) $

Are there more credit cards and loans payable to list?

Yes No

Name of Creditor (7)

Monthly Payment (7) $

Current Balance (7) $

Name of Creditor (8)

Monthly Payment (8) $

Current Balance (8) $

Name of Creditor (9)

Monthly Payment (9) $

Current Balance (9) $

Name of Creditor (10)

Monthly Payment (10) $

Current Balance (10) $

Name of Creditor (11)

Monthly Payment (11) $

Current Balance (11) $

Name of Creditor (12)

Monthly Payment (12) $

Current Balance (12) $

Total Credit Cards and Loans Monthly Payment $

Total Credit Cards and Loans Balance $

General Information

If you are married, these questions apply to both you and your spouse.

Are any assets held in Trust?

Yes No

Are any assets pledged or debts secured except as shown?

Yes No

Have you ever had a bankruptcy or had a judgment against you?

Yes No

Have you ever been a principal or guarantor of a firm that declared bankruptcy?

Yes No

What year did you file bankruptcy or had a judgment against you?

What year were you a principal or guarantor of a firm that declared bankruptcy?

Are you a party to any claim or law suit?

Yes No

Have you ever had a repossession?

Yes No

Has there been an IRS audit in the past 3 years?

Yes No