Personal Financial Statement[1]

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 $___________ Any significant changes expected in the next 12 months? [ ] Yes [ ] No (If yes, attach information.) ** Income from alimony, child support, or separate maintenance income need not be revealed if the applicant or co-applicant does not wish to have it considered as a basis for repaying this obligation. ANNUAL EXPENDITURES Federal Income and Other Taxes _____________________ AMOUNT ($) ___________ 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 $___________ Balance Sheet as of ____________ ASSETS Cash in this Bank _______________________________ (Including money market accounts, CDs) AMOUNT ($) ___________ 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 $__________ LIABILITIES Notes Payable to this Bank ________________________ Secured _________________________________ Unsecured _______________________________ Notes Payable to Others (E) _______________________ Secured _________________________________ Unsecured _______________________________ AMOUNT ($) ___________ ___________ ___________ ___________ ___________ ___________ 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? Are any of your tax obligations past due? [ ] Yes [ ] No $__________ [ ] 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 Monthly distribution if disabled Number of Years covered Applicant ________ ________ Co-Applicant ___________ ___________ 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)