TIB BANK PERSONAL FINANCIAL STATEMENT
INDIVIDUAL - If you are applying for an individual credit, and are relying on your own income or assets, and not on the income or assets of another person as the basis for repayment of the credit requested, complete all sections except joint/Other Party Information. JOINT - If you are applying for a joint credit with another person, complete all sections. If appropriate, the joint applicant may complete a separate TIB personal financial statement form, and the two forms may be submitted for application together.
If you intend to apply for joint credit, please initial here
Applicant Co-Applicant
Individual Information (Type or Print)
NOTE: Any willful misrepresentation could result in a violation of Federal Law (Sec. 18 U.S.C. 1014)
Name: Street Address: Business Name: Home Phone: Driver's License Number:
Birth Date: City: State/Zip: Bus. Or Occupation: Business Phone: E-mail/Website: State Issued Florida
Social Sec. Number: No. of Dependents: Length of Employment:
Joint/Other Party Information (Type or Print)
Name: Street Address: Business Name: Home Phone: Driver's License Number: ASSETS
1 2 3 4 5 6 7 Cash In Banks (Schedule D) Cash Value of Life Insurance (Schedule E) U.S. Gov. & Marketable Securities (Schedule F) Other Assets Readily Convertible to Cash:(Itemize)
City: Bus. Or Occupation: Business Phone: State Issued
Birth Date: State/Zip: E-mail/Website:
Social Sec. Number: No. of Dependents: Length of Employment:
STATEMENT OF FINANCIAL CONDITION AS OF _____________________, 20 __
In Dollars (Omit Cents)
LIABILITIES
Unpaid Taxes Due Loans on Life Insurance Policies (Schedule E) Loans on Marketable Securities (Schedule F) Credit Card Debt Other Liabilities Due within 1 Year: (Itemize)
In Dollars (Omit Cents)
8 Partial Interest in Real Estate (Schedule G) 9 Real Estate Owned (Schedule H) Accounts, Loans, Notes, Mortages Receivable 10 (Schedule I) 11 12 13 14 15 16 17 Interest In Non-Marketable Securities (to include CCorps, S-Corps, Ptnrshps, and LLCs) (Schedule J) Vehicles Other Assets: (Itemize) Personal property
Mortgage on Partially Owned Real Estate (Sch. G) Real Estate Mortgages Payable (Schedule H) Accounts, Loans, Notes Payable(other than included in Sch E, F, G, H & J)(Schedule K) Loans on Non-Marketable Securities (schedule J) Other Debt: (Itemize)
TOTAL ASSETS
Total Liabilities Net Worth (Total Assets minus Total Liabilities) TOTAL LIABILITIES & NET WORTH
Annual Income and Expenditures
Annual Income for Year-End __________, 20__ $ Salary, Bonuses & Commissions Annual Expenditures Taxes - Federal/State/Local $ Contingent Liabilities
Do you have any Contingent Liabilities As Endorser, Co-maker, or guarantor? On Leases or Contracts? Involvement in pending legal actions? Federal/State Income Tax If Yes to any, attach description Yes No
$ $ Other Income - Itemize $ (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.) $ $ Total Income $
Dividends & Interest Real Estate Income (Net)
$ $ $ Mortgage Payments Rent Payable $ Other Contract Payments (credit $ cards, auto) $ Alimony/Child Support $ $ Total Expenditures $
Real Estate Taxes Insurance Premiums
$ $ $ $ $
Total Contingent Liabilities
General Information - If yes, then attach explaination
Are you a U.S. Citizen? Yes No - Country _____________ No Yes Are you a defendant in any suits or legal actions? Are any assets held in trust? No No Yes Yes
Have you ever filed for bankruptcy protection in the last 14 years? (Explain):
Schedule D CASH IN BANKS
NAME OF BANK
Type of Account Name of Account Holder On Deposit
TOTALS
Schedules and attachments should be signed and dated by the individual and joint party(if applicable)
Schedule E
LIFE INSURANCE (List only those Policies that you own)
COMPANY
Face of Policy Cash Surrender Value Loans or Pledged Amount
Policy Holder
BENEFICIARY
TOTALS Schedule F
Face Value-Bonds No. of Shares Stock
(Note: Only the Cash Surrender Value Should be considered as an individual asset.)
SECURITIES OWNED (Including U.S. Gov't Bonds and all other Marketable Stocks and Bonds)
DESCRIPTION of Securities
In Name Of
COST
Market Value
Amount Pledged
To Whom Pledged
TOTALS Schedule G
Ownership%
PARTIAL INTERESTS IN REAL ESTATE EQUITIES
Description & Location
Date Acquired
Present Amount of Original Cost Value of Real Ins. Carried Estate
MORTGAGE OR CONTRACT PAYABLE Bal. Due Payment Maturity
To Whom Payable
TOTALS Schedule H
TITLE OWNERSHIP NAME
REAL ESTATE OWNED
Description & Location
Date Acquired
Present Amount of Original Cost Value of Real Ins. Carried Estate
MORTGAGE OR CONTRACT PAYABLE Bal. Due Payment Maturity
To Whom Payable
TOTALS Schedule I ACCOUNTS, LOANS, NOTES AND MORTGAGES RECEIVABLE
Maturity Date Term & Payment Amt. or Balance Due Good Accounts Date Full Payment Expected
Balance Due Doubtful Bal. Due Notes Rel. & Acc'ts Friends
MAKER/DEBTOR
SECURITY (If Any)
Schedule J
TOTALS INTEREST IN NON-MARKETABLE SECURITIES(To Include C-Corps, S-Corps, Ptnrshps, and LLCs)
Ownership %
Name of Entity/Security
Description of Entity/Security
Date of Financial Statement
Book Value Per Financial Statement
Market Value of Entity/Security
Amount of Liabilities including Contingent Liabilities
TOTALS Schedule K ACCOUNTS, LOANS, NOTES PAYABLE (other than included in Sch E, F, G, H and J)
Other Obligors (If Any) When Due
Notes Due to Rel. & Friends
Notes Due "Others" (Including Banks)
PAYABLE TO
Accounts & Bills Payable
Contracts Payable
COLLATERAL (If Any)
TOTALS
To induce TIB Bank of the Keys (“the bank”) to give or continue extensions of credit to, or at the request or for the benefit of the undersigned from time to time, and in consideration of any such extensions, the undersigned represent(s) and warrant(s) that the foregoing is a true and complete statement of the financial condition of the undersigned as of the date indicated and agree(s) that the Bank may rely upon it until notified in writing to the contrary by the undersigned. The undersigned agree(s) to provide the Bank with prompt written notice setting forth with specificity the nature of any material adverse change in the financial position of the undersigned subsequent to the date of this financial statement. The undersigned agree(s) that all obligations of every kind, direct and indirect, primary, secondary, contingent, sole and joint or several, of the undersigned to the Bank shall become immediately due and payable without notice or demand, notwithstanding the terms of any agreement to the contrary between the Bank and the undersigned or any third party relating to the obligations or the undersigned in favor of the Bank, in the event of a material misstatement or omission in the financial statement or the occurrence in the sole discretion of the Bank, of a material adverse change in the financial position of the undersigned subsequent to the date of the financial statement. The undersigned hereby authorize(s) the Bank to conduct or cause to be conducted credit investigations in order to verify all or the information provided in the financial statement. Further, the undersigned authorize(s) the Bank to obtain credit reports and such other information as may be required by the Bank from time to time. The undersigned acknowledge(s) that all such credit reports and documents furnished to the bank from whatever source as well as this financial statement shall be the property of the Bank, regardless of whether the financial accommodations sought by the undersigned are granted. In order to facilitate the Bank’s receipt of such credit information, the undersigned hereby authorize(s) any third party, which may be the subject of a request by the Bank to release to the Bank information concerning the credit history of the undersigned. Finally, the undersigned hereby waive(s) all claims to and against the Bank arising from and hold(s) the Bank harmless from and against any and all liability which it might incur in connection with the giving and receiving or credit information pertaining to the undersigned. 20 Date Signed Signature Date Signed 20 Signature - Of joint applicant