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Financial Statement Forms - DOC

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Financial Statement Forms - DOC Powered By Docstoc
					                                       PERSONAL FINANCIAL STATEMENT WORKSHEET

                                                           APPLICANT
FULL                                                               EMPLOYMENT/
NAME                                                               NAME OF BUSINESS
                                                                   (IF SELF EMPLOYED )
RESIDENCE                                                          POSITION
ADDRESS                                                            BUSINESS
CITY STATE                                                         ADDRESS
& ZIP                                                              BUSINESS PHONE
                                                                   NUMBER OF
PHONE                                                              DEPENDENTS

D.O.B                            SSN                               DRIVER’S LICENSES NO.

                                               CO -APPLICANT O R SPO USE

FULL                                                               EMPLOYMENT/
NAME                                                               NAME OF BUSINESS
                                                                   (IF SELF EMPLOYED)

RESIDENCE                                                          POSITION
ADDRESS                                                            BUSINESS
CITY STATE                                                         ADDRESS
& ZIP                                                              BUSINESS PHONE

PHONE        ______________________________________

D.O.B                            SSN                               DRIVER’S LICENSES NO.
______________


                             ASSETS                                           LIABILITIES & NET WORTH
                                                   Current Value                                                   Balance Owing
1. Cash (on hand & in banks)                                       13. Notes Payable, Banks, Unsecured
    (see schedule 1)                           $     0                 (see schedule 7)                        $
2. US Government & Agency Securities                               14. Notes Payable, Banks, Secured
    (see schedule 2)                           $                       (see schedule 7)                        $
3. Marketable Securities                                           15. Notes Payable. Others
   (see schedule 2)                            $                        (see schedule 7)                       $
4. Non-Marketable Securities                                       16. Loans Against Life Insurance
    (see schedule 3)                                                    (see schedule 4)                       $
                                                                   17. Accounts & Bills Payable
5. Notes Receivable--Itemize                   $                        (see schedule 7)                       $
6. Cash Value--Life Insurance                                      18. Real Estate Mortgages Payable
    (do not deduct loan) (see schedule 4)      $                        (see schedule 5)                       $
7. Real-estate in Own Name
   (see schedule 4)                            $                   19. Income Taxes Due                        $
8. Partial Interests in Real Estate--Net
    Equity Values (see schedule 6)             $                   20. State Taxes Due                         $
9. Automobiles
   Year Make                                   $                   21. Alimony/Child Support                   $
10. Furniture and Personal Property            $                   22. Other Liabilities--itemize
11. Other Assets--Itemize                      $                       Mortgage on partial interest in real    $
                                               $                          estate (sch. 6)



                                                                   23. TOTAL LIABILITIES                       $
                                                                   22. Net Worth                               $
                                               $                       (Total Assets Less Total Liabilities)
12. TOTAL ASSETS                                      $                     23. Total Liabilities & Net Worth               $
                                                                     A-13
            SOURCES OF ANNUAL INCOME                                                      GENERAL INFORMATION
Income from alimony, separate maintenance or child support need
not be revealed if you do not choose to rely on it in connection with
this financial statement.
                                                            Amount          Are you a partner, stockholder, or officer in
Salary/wages                                           $                    any other business venture?
                                                                                                                            % of Ownership
Commissions and Bonuses                                $                    If so, what

Dividends                                              $
                                                                            Have you entered into a separate or
                                                                            community property agreement with your
Real Estate Income                                     $                    spouse? If so, attach a copy.
                                                                            Do you have a will?
Proprietorship/Partnership                             $

Other Income--Itemize                                                       Name of Executor

Living Trust Income                                    $

                                                       $

            TOTAL ANNUAL INCOME                        $




                 CONTINGENT LIABILITIES                                          CASUALTY INSURANCE COVERAGE

                                                          Amount                              Company                           Amount


As Endorser, Guarantor or CO-Maker              $                       Homeowners:                                         $

On Leases or Contracts: Store lease             $                       Automobile:                                         $

Legal Claims                                    $                       Professional Liability:
                                                                        Are you, or have you ever been defendant in
Income Tax Claims                               $                       any legal actions, suits, or bankruptcy?
                                                                        Have you ever had any property posted for
                                                                        foreclosure or surrendered to the mortgage
Other--Itemize                                  $                       holder in lieu of foreclosure?

                                                $                       Explain:

                                                $
                                                    (Complete Schedules on Next Page)
                                          SUPPLEMENTARY SCHEDULES
                                        SCHEDULE 1 - BANKING RELATIONSHIPS
     Name & Location            Account Number            Checking           Savings        Retiremen           Collateral      High
       of Institution                                     Balances           Balances        t Funds                            Credit

                                                          $              $                  $                                  $

                                                          $              $                  $                                  $

                                                          $              $                  $                                  $

                                                          $              $                  $                                  $

                            SCHEDULE 2 - SECURITIES (GOV’T AND MARKETABLE)
No. Shares or                                                                           Source of       Registered in Name     % Stock
 Face Value               Description                 Cost          Market Value        Valuation               of             Pledged?

                                                 $                  $

                                                 $                  $

                                                 $                  $

                                                 $                  $

                                    SCHEDULE 3 - NON-MARKETABLE SECURITIES
            Description         No. Shares       No. Shares        Book Value       Financial       Total Value      Registered in Name
                                 Owned           Outstanding       Per Share        Statement                                of
                                                                                       Date

                                                                   $                                $

                                                                   $                                $

                                                                   $                                $

                                                                   $                                $

                                     SCHEDULE 4 - LIFE INSURANCE COVERAGE
    Face        Insurance Company       Owner of Policy       Name of Beneficiary         Total             Policy    Yearly       Is Policy
    Value                                                                                C.S.V.*            Loans    Premium       Assigned
                                                                                                                                       ?

$                                                                                    $                  $            $

$                                                                                    $                  $            $

$                                                                                    $                  $            $

$                                                                                    $                  $            $
*Cash Surre nde r Value
                                       SCHEDULE 5 - REAL ESTATE IN OWN NAME
     De scription         Dimension       Improve -   Purchase          Date         Market       Mortgage      Terms or   Mortgage         Monthly
Including Location of       s or #         ments       Price          Acquired       Value        Balance       Maturity    Holde r         Payme nt
       Addre ss             Acres                                                                                (Years)                    Amount



                                         $            $                          $                $                                      $



                                                      $                          $                $                                      $



                                         $            $                          $                $                                      $



                                         $            $                          $                $                                      $


              SCHEDULE 6 - PARTIAL INTERESTS IN REAL ESTATE - NET EQUITY VALUES
   De scription Including         Improveme nt       % of         Purchas    Date       Market        Mortgag     Terms    Mortgag      Monthly
    Location of Addre ss               s          O wnershi       e Price   Acquire     Value            e          or     e Holde r    Payme nt
                                                      p                        d                      Balance    Maturit
                                                                                                                    y
                                                                                                                 (Years)



                                  $                            $

                                  $                            $                        $             $                                 $

                                  $                            $                        $             $                                 $

                                  $                            $                        $             $                                 $
*Note:   Share ownership with three siblings


SCHEDULE 7 - BANK, FINANCE COMPANIES, SAVINGS & LOAN ASSOCIATIONS, STORES, AND
              INDIVIDUALS FROM WHOM CREDIT HAS BEEN OBTAINED.**
                                                              O riginal     Maturity            High      Current       Monthly        Collateral
            Name                          Address             Loan          or Terms            Credit    Balance      Payments
                                                              Balance

                                                              $                             $             $            $

                                                              $                             $             $            $

                                                              $                             $             $            $

                                                              $                             $             $            $




**Include: Lines of credit, loans against retirement plans, and loans secured by savings/CDs

				
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