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									                                 PERSONAL FINANCIAL STATEMENT
                                          MADISON BANK

  NAME: _________________________________                  DATE: ________________________
  ADDRESS: _____________________________                   TELEPHONE #: ____________________________
SOCIAL SECURITY #:______________________                   BUSINESS TELEPHONE #: __________________
DATE OF BIRTH: _________________________
NAME OF OTHER PERSON(S) TO BE CONTRACTUALLY LIABLE:__________________________________

      ASSETS                             $$ (Omit Cents)           LIABILITIES                         $$ (Omit Cents)

 CURRENT ASSETS                                            CURRENT LIABILITIES (1 year or less)
Cash on Hand                                               Note(s) Payable (This Bank) (See Sched)
Checking Deposits in Banks                                 Note(s) Payable (Other Banks) (See Sched)
Savings Deposits in Banks                                  Line(s) of Credit
Certificates of Deposits                                   Credit Card(s) Debt (See Schedule)
Cash Value of Life Insurance                               Accounts & Bills Payable
Bonds & Securities (See Schedule)                          Loans on Life Insurance Policies
  Motor Vehicles Present Value:                            Federal & State Income Taxes
Year:          Model:                                      Rents & Interest Due
Year:          Model:                                      Real Estate Taxes Due but Unpaid
Year:          Model:                                      Other Liabilities Due Within 1 Year
Year:          Model:
Year:          Model:
Other Current Assets (Describe):

                                                              TOTAL CURRENT LIABILITIES                            $0

                                                                LONG TERM LIABILITIES
     TOTAL CURRENT ASSETS:                           $0
                                                           Mortgages on Real Estate (See Sched)
  FIXED ASSETS                                             Notes Payable (Individuals) (See Sched)
                                                           Notes Payable to Banks Other than
Notes or Mortgages Due Me                                  Mortgages (See Sched)
Real Estate Owned (See Schedule)                           All Other Long Term Debts (Describe):
Other Pers. Property & Household Goods
Retirement Plans
Ownership of Closely Held Business
Partnership Interests (Describe)

                                                             TOTAL LONG TERM LIABILITIES                           $0
Other Fixed Assets (Describe)

                                                               TOTAL LIABILITIES                                   $0

    TOTAL FIXED ASSETS                               $0        NET WORTH                                           $0

      TOTAL ASSETS                                   $0    TOTAL LIABILITIES & NET WORTH                           $0

     Revised 11/14/2003 (JLP)
With each schedule list below, indicate co-ownership, if any, and the extent of it:

                                   SCHEDULE OF LIFE INSURANCE
                                                                                                       CASH          LOANS
                                     FACE VALUE                                                     SURRENDER        AGAINST
             Company                  OF POLICY                         BENEFICIARY                   VALUE          POLICY

              TOTALS                            $0                                                              $0          $0

                                                                                                                     Pledged to
                                                      # Of                                            Market           Secure
     Description of Security         Cost Price      Shares   Security Held Jointly/Individually      Value            Loans

              TOTALS                            $0                                                              $0          $0

                         SCHEDULE OF REAL ESTATE OWNED (Residential and Other)
                                                                                                     Current          Monthly
    Description & Location of         Present                                                       Balance of        Payment
            Property                   Value                    Title in the Name of:               Mortgage          Amount

              TOTALS                            $0                                                              $0          $0

                SCHEDULE OF LOANS, NOTES, OR MORTGAGES (All Banks, Institutions, or Individuals)

                                                                                                   Current Amount     Monthly
  Description of Loan, Note, or    Original Note To Whom Loan, Note, or Mortgage is Payable         of Loan, Note,    Payment
            Mortgage                 Amount                        to:                               or Mortgage      Amount

              TOTALS                            $0                                                              $0          $0

                                       SCHEDULE OF CREDIT CARD DEBT
                                      Current                                                         Monthly
                                    Credit Card                                                       Payment
    Description of Credit Card       Balance                   To Whom Payable To:                    Amount

              TOTALS                            $0                                                              $0

    Revised 11/14/2003 (JLP)
     SOURCES OF INCOME                                                                              PERSONAL INFORMATION
Salary, Bonus & Commissions                                                     Business or Occupation
Dividends                                                                       Employer
Real Estate Income                                                              Partner or Officer in Another Venture
NOTE: Alimony, child support, or separate maintenance income need
not be revealed if you do not with to have it considered as a basis for

Other Income - Itemize                                                                          Do You Have a Will?                          Yes               No
If Joint Financial Statement, Please List the
Following:                                                                                       Name of Executor
Joint Individual's Salary, Bonus, &
Commissions                                                                     Personal Bank Account - Where Carried
NOTE: Alimony, child support, or separate maintenance income need
not be revealed if you do not with to have it considered as a basis for
repayment.                                                                      Savings Account - Where Carried
Joint Individual's Other Income - Itemize                                       Name Business Dealing with this Bank in Past
Total Income                                                   $0
                                                                                                         Yearly Expense Projection
Contingent Liabilities
As Endorser, Co-Maker, or Guarantor                                             Federal & State Income Tax
On Leases or Contracts                                                          Mortgage Payments
Legal Claims                                                                    Rent
Provision for Federal Income Taxes                                              Insurance Premiums
Other Special Debt - Itemize                                                    Total Credit Card Payments
Total Contingent Liabilities                                   $0               Other Expenses
                                                                                Total Yearly Expenses                                                $0

                                                            Other Pertinent Information
Fire Insurance On Buildings                        $                            Other Liabilities Due Within 1 Year                   $

Have you ever made a compromise settlement with Creditors or been adjudged bankrupt in the last 10
years?                                                                                                                                       Yes               No

Are any suits, judgments, or litigation pending either for or against you?                                                                   Yes               No

If yes to the above, please describe?

I/We hereby affirm that the information contained in this financial statement is presented for the purposed of obtaining credit as of the date indicated, and is true,
complete and correct. I/We understand that the Financial Institution is relying on this statement of my/our financial condition in making a loan(s) to me/us. The
Financial Institution is authorized to make any investigation of my/our credit or employment status either directly or through any agency employed by the
Financial Institution for that purpose. The Financial Institution may disclose to any other interested parties the Financial Institution's experience with my/our
account. I/We agree to inform the Financial Institution immediately of any matter which will cause any significant change in my/our financial condition. I/We
understand the Financial Institution will retain this financial statement whether or not credit is granted.

  X __________________________________________                                    X __________________________________________
        Signature of Applicant                                                           Signature of Applicant

CONSENT: (If you are relying on income from a person who is not an applicant above, please have that person complete this section, so that we may verify
their personal credit):
I authorize the Financial Institution to make any investigation of my credit either directly, or through any agency employed by the Financial Instiution for that
purpose, in connection with this credit application.

Signature/SS#                               Date                                Signature/SS#                               Date

If the Personal Financial Statement is being submitted to MADISON BANK Company from either the Borrower, Co-Borrower, or
Guarantor, via e-mail, is the information which is provided, correct based upon the above statement?                                         Yes               No

Signature/SS#                               Date                                Signature/SS#                               Date

If the Personal Financial Statement (PFS) is being transferred via e-mail by the Lender, is there a
signed copy of the PFS in the loan credit file?                                                                                              Yes               No

Signature/SS#                               Date                                Signature/SS#                               Date

     Revised 11/14/2003 (JLP)
Revised 11/14/2003 (JLP)
Revised 11/14/2003 (JLP)





Revised 11/14/2003 (JLP)

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