Docstoc

Loans Secured by Tax Refund

Document Sample
Loans Secured by Tax Refund Powered By Docstoc
					FARMERS AND RANCHERS

Confidential Financial Statement as of

NAME                                                                       DATE OF BIRTH                         EMPLOYER                                  YEARS



HOME ADDRESS                                            HOME PHONE         CELL PHONE          OCCUPATION                                                  YEARS



CITY / STATE / ZIP CODE                                 SOCIAL SECURITY NUMBER                 E-MAIL ADDRESS



PROPRIETORSHIP, PARTNERSHIP, OR CORPORATION             DRIVER'S LICENSE NO. & STATE           BUSINESS ADDRESS




                          ASSETS                                     (OMIT CENTS)                               LIABILITIES                                 (OMIT CENTS)


                                    CURRENT ASSETS                                                              CURRENT LIABILITIES (Due in 12 months)
CASH ON HAND & IN FINANCIAL INSTITUTIONS (Schedule 1)                                          UNSECURED NOTES PAYABLE (Schedule 8)
                                                         $                                 -                                                           $                       -
GOVERNMENT BONDS & SECURITIES                                                                  LOANS SECURED BY LIVESTOCK (Schedule 9)
                                                                                                                                                                               -
OTHER INVESTMENTS (Schedule 2)                                                                 LOANS ON FARM MACHINERY & AUTOS (Sch. 10)
                                                                                           -                                                                                   -
FARM PRODUCTS, GRAIN, AND FEED ON HAND (Schedule 3)                                            OTHER LOANS (Schedule 11)
                                                                                           -                                                                                   -
LIVESTOCK OWNED (Schedule 4)                                                                   ACCOUNTS PAYABLE
                                                                                           -
ALL OTHER CURRENT ASSETS                                                                       INTEREST DUE & PAYABLE


                                                                                               PAYROLL TAXES


                                                                                               REAL ESTATE TAXES DUE & PAYABLE


                                                                                               INCOME TAXES DUE & PAYABLE


                                                                                               INCOME TAXES ESTIMATED FOR CURRENT YEAR


                                                                                               ALL OTHER CURRENT DEBTS (Itemize)




            TOTAL CURRENT ASSETS                         $                                 -           TOTAL CURRENT ASSETS                            $                       -
                                       FIXED ASSETS                                                                        LONG TERM LIABILITIES
FARM MACHINERY and AUTOMOTIVE EQUIPMENT (Sch. 5)                                               LIENS ON FARM & RANCH LANDS (Schedule 12)
                                                         $                                 -                                                           $                       -
FARM and RANCH LANDS (Schedule 6)                                                              LIENS ON OTHER REAL ESTATE (Schedule 13)
                                                                                           -                                                                                   -
OTHER REAL ESTATE (Schedule 7)                                                                 ALL OTHER LONG TERM DEBTS (Itemize)
                                                                                           -
CASH VALUE OF LIFE INSURANCE


OTHER FIXED ASSETS (Itemize)




                                                                                                   TOTAL LONG TERM LIABILITIES $                                               -
PERSONAL PROPERTY                                                                              TOTAL LIABILITIES                                       $                       -
              TOTAL FIXED ASSETS                         $                                 - NET WORTH (Assets less Liabilities)                       $                       -
TOTAL ASSETS                                             $                                 -   TOTAL LIABILITIES & NET WORTH $                                                 -

                                                  SCHEDULE 1 - CASH ON HAND & IN FINANCIAL INSTITUTIONS
   STYLE OF ACCOUNT                 NAME & LOCATION WHERE HELD                  BALANCE              TYPE OF ACCOUNT                       ACCOUNT #        RESTRICTED YES OR NO




                                                             TOTAL          $              -
                                   SCHEDULE 2 - OTHER INVESTMENTS (INCLUDE STOCKS & BONDS)

NAME OF ISSUER         TYPE OF INVESTMENT             MATURITY           PURCHASE PRICE              CURRENT VALUE           RESTRICTED YES OR NO




                                                                                        TOTAL    $                   -



                                     SCHEDULE 3 - FARM PRODUCTS, FEED, AND GRAIN ON HAND

                    QUANTITY
    CROP                                           WHERE STORED                              PRICE PER UNIT                      TOTAL VALUE
                 (BU, BALE, CWT)




                                                                                                        TOTAL            $                          -



                                                   SCHEDULE 4 - LIVESTOCK

                                                                    AVG. WEIGHT
    CLASS                     BREED                NUMBER OF HEAD                      MARKET VALUE PER HEAD                     TOTAL VALUE
                                                                     PER HEAD




                                                                                                              TOTAL      $                          -



                                   SCHEDULE 5 - FARM MACHINERY & AUTOMOTIVE EQUIPMENT

 DESCRIPTION                  MAKE                    QUANTITY                            COST                                  PRESENT VALUE




                                                                                                              TOTAL      $                          -



                                              SCHEDULE 6 - FARM & RANCH LANDS

    ACRES               LEGAL DESCRIPTION (COUNTY & STATE)                      NATURE OF IMPROVEMENTS                          MARKET VALUE




                                                                                                              TOTAL      $                          -



                                               SCHEDULE 7 - OTHER REAL ESTATE

    ACRES               LEGAL DESCRIPTION (COUNTY & STATE)                      NATURE OF IMPROVEMENTS                          MARKET VALUE




                                                                                                              TOTAL      $                          -
                          SCHEDULE 8- UNSECURED NOTES PAYABLE TO FINANCIAL INSTITUTIONS

NAME OF LENDER      PURPOSE OF LOAN                 ORIGINAL AMOUNT           AMOUNT OWED       WHEN DUE   REPAYMENT PLAN




                                                                 TOTAL $                    -



                                       SCHEDULE 9- LOANS SECURED BY LIVESTOCK

NAME OF LENDER         SECURITY                     ORIGINAL AMOUNT           AMOUNT OWED       WHEN DUE   REPAYMENT PLAN




                                                                 TOTAL $                    -


                         SCHEDULE 10- LOANS ON FARM MACHINERY & AUTOMOTIVE EQUIPMENT

NAME OF LENDER         SECURITY                     ORIGINAL AMOUNT           AMOUNT OWED       WHEN DUE   REPAYMENT PLAN




                                                                 TOTAL $                    -


                                      SCHEDULE 11- OTHER LOANS (NON-REAL ESTATE)

NAME OF LENDER      PURPOSE OF LOAN                 ORIGINAL AMOUNT           AMOUNT OWED       WHEN DUE   REPAYMENT PLAN




                                                                 TOTAL $                    -



                                      SCHEDULE 12- LIENS ON FARM & RANCH LANDS

NAME OF LENDER   DESCRIPTION & LOCATION             ORIGINAL AMOUNT           AMOUNT OWED       WHEN DUE   REPAYMENT PLAN




                                                                 TOTAL $                    -



                                       SCHEDULE 13- LIENS ON OTHER REAL ESTATE

NAME OF LENDER   DESCRIPTION & LOCATION             ORIGINAL AMOUNT           AMOUNT OWED       WHEN DUE   REPAYMENT PLAN




                                                                 TOTAL $                    -
                                                                                            SCHEDULE 14 - PROPERTY INSURANCE
   PROPERTY COVERED                                                 INSURANCE COMPANY                                                                         POLICY NUMBER                                                       AMOUNT




                                                                                                   SCHEDULE 15 - LIFE INSURANCE
                     INSURANCE COMPANY NAME                                                     POLICY NUMBER                                   FACE AMOUNT                          CASH VALUE                                 BENEFICIARY




                                                                                                INCOME / EXPENSE INFORMATION
                                                                                      THIS YEAR             PROJECTED NEXT                                                                                                                  PROJECTED NEXT
                     SOURCES OF CASH                                                     20__                  YEAR 20__
                                                                                                                                                          USES OF CASH                                       THIS YEAR             20__
                                                                                                                                                                                                                                               YEAR 20__

RECURRING                                                                                                                             EXPENSES

           SALARY & WAGES                                                                                                                                     INCOME TAXES & FICA

           COMMISSIONS                                                                                                                                        OTHER PAYROLL DEDUCTIONS

           BONUS                                                                                                                                              LIVING EXPENSES

           INTEREST                                                                                                                                           RENTAL EXPENSES

           DIVIDENDS                                                                                                                                          FARM EXPENSES

           RENTAL INCOME                                                                                                                                      OTHER EXPENSES

           FARM INCOME

           OTHER INCOME

                                      SUBTOTAL                                                                                                                   SUBTOTAL
                                                                                  $                    -    $                     -                                                                           $                        -    $                     -
NON-RECURRING                                                                                                                         DEBT SERVICE

           COMMISSIONS

           BONUS

           SALE OF ASSETS

           TAX REFUND

           OTHER INCOME

                                                                                                                                                            TOTAL CASH USES
                                                                                                                                                                                                              $                        -    $                     -
                        TOTAL CASH SOURCES                                        $                    -    $                     -                           NET CASH FLOW                                   $                        -    $                     -


                                                                                                   SUPPLEMENTAL INFORMATION
LEASE OR OWN                     NUMBER OF ACRES                                 LOCATION (COUNTY & STATE)                                                   TAXES PAID TO (DATE)                             MORTGAGE INTEREST PAID TO (DATE)



DATE LEASED                      TERM OF LEASE                                   ANNUAL RENTAL                                                               DATE PAID TO



HAVE YOU ANY CONTINGENT LIABILITIES AS ENDORSER, CO-MAKER, GUARANTOR, LEASES, CONTRACTS, OR LETTERS OF CREDIT?



HAVE YOU ANY PARTNERS IN YOUR BUSINESS?



HAS AN ACTION IN BANKRUPTCY EVER BEEN FILED FOR OR AGAINST YOU?                                                                       HAVE YOU ANY JUDGMENTS OR SUITS PENDING AT THIS TIME?



TAX RETURN HAS BEEN FILED THROUGH :                                                                                                   ANY ADDITIONAL ASSESSMENTS?                                            AMOUNT:


The above financial and supporting schedules, which are submitted to you for the purpose of obtaining credit from you, present a true, complete and correct statement of my financial condition as of the date shown. I understand that misrepresenting
information on this statement is a criminal offense under federal law punishable by a fine and/or imprisonment.


I will notify you in writing of any material unfavorable change in my financial condition. In the absence of such notice, you may consider this a continuing statement and substantially correct. If I apply for further credit, this statement shall have the same
force and effect as if delivered as an original statement of my financial condition at the time I request such further credit. You are authorized to contact any appropriate third parties for the purpose of verifying any stated information herein or at any time
furnished by me to you, and obtaining credit information at any time from any of my creditors and or credit reporting agencies. This financial statement and any other information furnished to you shall be your property. You are authorized to answer
questions about your credit experience with me.



Witness                                                                   Date                             Signature                                                                                         Date

				
DOCUMENT INFO
Description: Loans Secured by Tax Refund document sample