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PERSONAL FINANCIAL
STATEMENT
APPLICANT PLEASE TYPE OR PRINT CLEARLY. ANSWER ALL ITEMS. IF “NONE” SO STATE.
NAME OF BORROWER (LAST, FIRST, MIDDLE) SOCIAL SECURITY NUMBER
STREET ADDRESS CITY STATE ZIP
HOME PHONE WORK PHONE EMAIL ADDRESS DATE OF BIRTH
EMPLOYER POSITION YRS THERE ANNUAL INCOME
EMPLOYER STREET ADDRESS CITY STATE ZIP
SUPERVISOR PHONE WORK EMAIL ADDRESS
EMPLOYER (IF CURRENT IS LESS THAN 2 YEARS) POSITION YRS THERE ANNUAL INCOME
EMPLOYER STREET ADDRESS CITY STATE ZIP
SUPERVISOR PHONE WORK EMAIL ADDRESS
CO-APPLICANT P LEASE TYPE OR PRINT CLEARLY. ANSWER ALL ITEMS. IF “NONE” SO STATE.
NAME OF BORROWER (LAST, FIRST, MIDDLE) SOCIAL SECURITY NUMBER
STREET ADDRESS CITY STATE ZIP
HOME PHONE WORK PHONE EMAIL ADDRESS DATE OF BIRTH
EMPLOYER POSITION YRS THERE ANNUAL INCOME
EMPLOYER STREET ADDRESS CITY STATE ZIP
SUPERVISOR PHONE WORK EMAIL ADDRESS
EMPLOYER (IF CURRENT IS LESS THAN 2 YEARS) POSITION YRS THERE ANNUAL INCOME
EMPLOYER STREET ADDRESS CITY STATE ZIP
SUPERVISOR PHONE WORK EMAIL ADDRESS
BALANCE SHEET
Assets Liabilities
1. Cash (Schedule A) $ 16. Loans Payable to Bank – Unsecured (Schedule I) $
2. Marketable Securities (Schedule B) 17. Loans Payable to Bank – Secured (Schedule I)
3. Accounts & Notes Receivable (Schedule C) 18. Loans Payable to Others
4. Cash Surrender Value – Life Insurance (Schedule 19. Mortgage Payable (Schedule J)
D)
5. Real Estate Owned – Market Value (Schedule E) 20. Installment Contracts Payable
6. Mortgage Owned (Schedule F) 21. Federal & State Income Taxes Payable
7. Business Interests – Market Value (Schedule G) 22. Other Taxes & Interest Payable
8. Business Investments – Cost (Schedule H) 23. Loans Against Cash Surrender Value – Life Ins.
9. Pensions, IRA, 401K, Keogh 24. Other Liabilities (Schedule K)
10. Other Assets (Describe): 25. Other (Describe):
11. Other Assets (Describe): 26. Other (Describe):
12. Other Assets (Describe): 27. Other (Describe):
13. Other Assets (Describe): 28. TOTAL LIABILITIES $
14. Other Assets (Describe): 29. NET WORTH $
15. TOTAL ASSETS $ 30. TOTAL LIABILITIES & NET WORTH $
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REMINDER – IF NOT COMPLETED JOIN TLY, LIST ONLY YOUR PROPORTIONATE INTEREST IN ANY JOIN TLY HELD ASSETS & LIABILITIES.
SCHEDULE A – CASH BA LANCES
ACCOUNT TYPE PLEDGED?
NAME AND LOCATION OF DEPOSITORY & ACCOUNT NUMBER ACCOUNT SIGNORS Y/N CASH BALANCE
$
TOTAL CASH BALANCES $
SCHEDULE B – MARKETABLE SECURITIES
PLEDGED?
NAME/DESCRIPTION OF SECURITIES NUMBER OF SHARES REGISTERED OWNER(S) Y/N MARKET VALUE
$
TOTAL MARKET VALUE $
SCHEDULE C – ACCOUNTS & NOTES RECEIVABLE
INTEREST MATURITY ANNUAL REMAINING
DUE FROM ORIGINAL AMOUNT RATE DATE COLLATERAL PAYMENT BALANCE
$
TOTAL RECEIVABLES BALANCE $
SCHEDULE D – LIFE INSURANCE
FACE PLEDGED?
INSURANCE COMPANY NAME POLICY NUMBER OWNER AMOUNT BENEFICIARY Y/N NET CASH VALUE
$ $
TOTAL NET CASH VALUE $
SCHEDULE E – REA L ESTATE OW NED
DATE MORTGAGED?
LOCATION & TYPE ACQUIRED % OWNED COST NET RENTAL INCOME Y/N MARKET VALUE
$ $ $
TOTAL MARKET VALUE $
2
SCHEDULE F – MORTGA GES OWNED
ANNUAL MATURITY ASSIGNED? REMAINING
LOCATION/TYPE OF PROPERTY MORTGAGOR INCOME DATE Y/N BALANCE
$ $
TOTAL MORTGAGES OWNED BALANCE $
SCHEDULE G – BUSINESS INTERESTS
ANNUAL ANNUAL NET
NAME & BUSINESS TYPE DATE ACQUIRED % OWNED COST REVENUE INCOME MARKET VALUE
$ $ $ $
TOTAL MARKET VALUE $
SCHEDULE H – BUSINESS INVESTMENTS
CASH DISTRIBUTIONS
NAME & BUSINESS TYPE DATE ACQUIRED % OWNED COST PRIOR YEAR CURRENT YEAR NET EQUITY
$ $ $ $
TOTAL NET EQUITY $
SCHEDULE I – LOANS PAYABLE
ORIGINAL INTEREST MATURITY MONTHLY CURRENT
NAME &LOCATION OF LENDER AMOUNT COLLATERAL DESCRIPTION RATE DATE PAYMENT BALANCE
$ $ $
TOTAL LOAN BALANCES $
SCHEDULE J – MORTGAGES PA YABLE
ORIGINAL INTEREST MATURITY MONTHLY CURRENT
NAME &LOCATION OF LENDER AMOUNT COLLATERAL ADDRESS RATE DATE PAYMENT BALANCE
$ $ $
TOTAL MORTGAGE BALANCES $
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SCHEDULE K – O THER LIABILITIES
ORIGINAL INTEREST MATURITY MONTHLY CURRENT
OWED TO AMOUNT COLLATERAL RATE DATE PAYMENT BALANCE
$ $ $
TOTAL OTHER LIABIL ITIES $
INCOME & EXPENSES
INCOME Applicant Co-Applicant EXPENSES Applicant Co-Applicant
Salary $ $ Personal Living Expenses $ $
Interest/Dividends Loans Payable
Rental Income Mortgages Payable
Business Income Business Contributions
Capital Gains Taxes
Other Income Other Expenses
TOTAL INCOME $ $ TOTAL EXPEN SES $ $
DESCRIBE SOURCE OF OTHER INCOME ABOVE DESCRIBE OTHER EXPENSES ABOV E
Have any judgments been entered against you? YES NO
If so, please describe:
Have you ever filed bankruptcy? YES NO
If so, when and where:
The information contained in this statement is provided for the purpose of obtaining or maintaining credit with you on my/our behalf or on the behalf of persons, firms, or
corporations in whose behalf I/we may, either severally or jointly with others, execute a guaranty in your favor. I/we understand that you are relying on this information
(including the designation made as to ownership of property) in deciding to grant or continue credit. I/we represent and warrant that the information provided is true and
complete and that you may consider this statement as continuing to be true and correct until a written notice of change is gi ven to you by me/us. I/we agree to notify you
promptly of any such change. You are authorized to check the statements made on this form, run credit reports from any repor ting agency, and to determine my/our
creditworthiness. You will tell me/us upon request whether or not a consumer report was requested and, if so, inform me/us of the name and address of the consumer
reporting agency. You are authorized to answer questions about your credit experience with me/us. You may order additional consumer reports and otherwise check my/our
credit at any time while credit is outstanding in conjunction with an update, renewal, refinance, or extension of such credit or in connection with collection efforts. You may
retain this statement whether or not credit is approved.
Applicant Co-Applicant
Signature Signature
Date Date
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