PERSONAL FINANCIAL STATEMENT CONFIDENTIAL
PERSONAL INFORMATION
Please Print or Type Name (Applicant) If joint statement, complete the following: Name ( Co-Applicant)
Name
Date of Birth Social Security Number Date of Birth Social Security Number
XX / XX / XX
Street Address
xxx - xx - xxxx
Street Address
1234 Main Street
City, State, Zip Code City, State, Zip Code
City, State 48900
Home Phone Number Business Phone Number Home Phone Number Business Phone Number
517-123-4567
Present Employer
517-765-4321
Present Employer
Eloquent Jewelry Design
Street Address Street Address
1234 Main Street
City, State, Zip Code City, State, Zip Code
City, State 48900
Position No. of Years Position No. of Years
Owner
25 FAMILY INFORMATION
No. of Children/Dpndnts
Ages
Do you have a will?
If yes, date of will
Name of Personal Representative
No
Do you have a trust? If yes, date of trust Name of Trustee/Successor Trustee
No Cash Income and Expenditures Statement For the Year Ending: ANNUAL INCOME
Salary (Applicant) Salary (Co-Applicant) Bonuses & Commissions Dividend Income Interest Income Rental Income S-Corp Withdrawls Other Gains/Losses Other Investment Income Other Income (List)* IRA Withdrawals $
12/31/2005 ANNUAL EXPENDITURES
Property Taxes/Assessments Income, State, and Other Taxes $
AMOUNT ($) 15,000.00
AMOUNT ($) 2,500.00 5,900.00 0.00 22,000.00 5,000.00 10,000.00 50,000.00 13,000.00 0.00 0.00 0.00 0.00 108,400.00
0.00 0.00 150.00 700.00 5,000.00
Rental Payments Mortgage Payments (Principal & Interest) Other Loan Payments (Rental House) Contract Payments (Car, Charge Card, Etc.) Partnership/Sub-S Contributions (E, F) Insurance Payments Alimony, Child Support Maintenance Education Expenses
185,000.00 205,850.00
Other Living Expenses Other Expense
TOTAL INCOME
$
TOTAL EXPENDITURES
$
The undersigned need not disclose income from alimony, child support or separate maintenance payments if such income is not to be considered as a source for repayment of the financial accommodations.
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STATEMENT OF ASSETS AND LIABILITIES DATED AS OF: * All Figures should be in dollars. * Please attach a separate schedule if more space is needed. Brokerage statements or other such statements may serve in place of * Please use the columns labeled HUSBAND and WIFE for assets owned solely by one or the other and use the JOINT column for all assets owned jointly between the two individuals. If owned jointly with an outside party, please include in the JOINT column but note with an asterisk. Include all assets held by you as a trustee of your living trust in the trust column. Samantha Durisin ASSETS HUSBAND WIFE JOINT TRUST LIABILITIES HUSBAND WIFE JOINT TRUST
Cash Held in Financial Institutions Pledged Not Pledged Pledged Not Pledged Marketable Securities (A) Accounts & Notes Receivable (B) Net Cash Surrender Value of Life Insurance (C) Residence (D) Other Real Estate (D) Sub S CorporationReal Estate (E) Sub S Corporation (Not Real Estate) (F) IRA, Pension, & Profit Sharing Automobiles Recreational Vehicles Personal Property - Includes guns, antiques and household items Loans Payable (G) Secured
27,500 19,700
45,200
Unsecured Accounts & Bills Due Credit Cards Payable Loans against Life Insurance Policy (C) Mortgage Payable Residence (D) Mortgage Payable Other Real Estate (D) Mortgage Payable - (E) Real Estate Sub-S Corps Notes Payable - (F) Other Sub-S Corps Taxes Payable Other Liabilities (List)
0 0 170,000 75,800 500,000 200,000 0
140,000 16,000 300,000 200,000 1,000,000 220,000 0 40,000 30,000
80,000
TOTAL LIABILITIES NET WORTH
993,000 1,078,200 0 2,071,200
TOTAL
0
0 2,071,200
0
TOTAL
NOTE: NET WORTH = TOTAL ASSETS - TOTAL LIABILITIES
CONTINGENT LIABILITIES
Contingent Liabilities for this purpose are defined as obligations that may require payment to be made in the future.
YES/NO
Are (either of) you a guarantor, co-maker, or endorser of any debt of an individual, corporation, or partnership? Do you have any outstanding letter of credit or surety bonds? Are you contingently liable on any lease or contract? Are any of your tax obligations past due? Any other contingent liabilities that may have a material affect on the information provided?
AMOUNT $ $ $ $ $
NO NO NO NO NO
If additional detail is needed for any of the items above, please use the space provided below:
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SUPPORTING SCHEDULES
SCHEDULE A - MARKETABLE SECURITIES*
No. of shares (Stock) or Face Value (Bond) DESCRIPTION OWNED BY COST CURRENT MARKET VALUE IF PLEDGED = P RESTRICTED = R
READILY MARKETABLE SECURITIES (Including U.S. Government and Municipals)
OTHER MARKETABLE SECURITIES (Closely held or thinly traded)
*Brokerage Statement may be included and only totals entered
Total
SCHEDULE B - ACCOUNTS AND NOTES RECEIVABLE
NAME OF DEBTOR COLLATERAL MONTHLY PAYMENT MATURITY DATE UNPAID BALANCE
Total SCHEDULE C - LIFE INSURANCE
NAME OF INSURED Samantha Durisin INSURANCE COMPANY Company POLICY OWNER Samantha Durisin BENEFICIARY AMOUNT 100,000 CASH VALUE 10,000 LOANS ON POLICY 0
Total SCHEDULE D - REAL ESTATE AND MORTGAGES
ADDRESS 1234 Main St. 999 Main St. 888 Main St. PROPERTY TYPE Residence Rental Cabin % LEASED % OWNED 100 100 100 500 PERSONAL LIABILITY NET OP. INCOME ANNUAL DEBT SERVICE 18,000 6,000 2,000 LENDER Bank Bank Bank MTGE. OUTSTAND. 160,000 70,000 5,000 MARKET VALUE 300,000 160,000 75,000
*For additional space, please use the attached page
Total
235,000
535,000
SCHEDULE E - SUB-S CORP (REAL ESTATE)
SUB-S CORP PROPERTY LOCATION % LEASED NET OP. INCOME DEBT SERVICE % OWNED PERSONAL LIABILITY MTGE. OUTSTAND. MARKET VALUE WITHDRAWALS (CONTRIBUTIONS)
22000
*For additional space, please use the attached page
Total
SCHEDULE F - SUB-S CORP (NOT REAL ESTATE)
INVESTMENT NAME DATE OF INITIAL INVESTMENT INVESTMENT AMOUNT % OWNED LOANS OUTSTANDING MARKET VALUE WITHDRAWALS (CONTRIBUTIONS
Total SCHEDULE G - OTHER LOANS PAYABLE
TO WHOM Bank Bank ADDRESS NAME OF DEBTOR COLLATERAL Car Car INT RATE MATURITY DATE MONTHLY PAYMENT 400 300 UNPAID BALANCE 13,550 3,339
Total
Please check if aditional forms are included
700
16,889
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GENERAL INFORMATION Have (either of) you or any company in which (either of) you were a major owner ever declared bankruptcy in the last seven years? Samantha Durisin Have (either of) you ever had a judgment against you? XX / XX / XX xxx - xx - xxxx Are any assets pledged or debts secured except as shown? If yes, please indicate on a separate sheet which assets and their value. Are (either of) you a defendant in any suits or legal action? Have any of your tax returns been audited or contested? Do either of you have a line of credit or unused facility at any other financial institution? If yes, please indicate the institution, the amount, and the name of your Account Officer. If you have answered "yes" to any of the above questions, please explain in the space provided below or on a separate sheet.
Yes X Yes X Yes X
No No No
Yes X Yes X Yes X
No No No
2000 6000 YOUR REPRESENTATIONS AND WARRANTIES I understand that recipient is relying on the accuracy and completeness (including contingent liabilities and my property designation as individually or jointly held) of the information provided in this financial statement, in deciding to give or continue authorized to conduct such investigation into my financial affairs as you deem necessary, including a consumer credit report. If this is a joint financial statement, this certificate is from each of us. 22000 5000 10000 120000 13000
Date
Signature
Date
Signature of Joint Applicant
THIS FORM MUST BE SIGNED BY BOTH APPLICANTS
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