Request to Renewal of Bank Loan by bem21275


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									                                                    Personal Financial Statement
                                                         As of
Name                                                                      Name
Address                                                                   Address
Business                                                                  Business
Occupation                                                                Occupation
Home Phone                              Work Phone                        Home Phone                             Work Phone
Cell Phone                                                                Cell Phone
E-mail                                                                    E-mail
DOB                                          SSN                          DOB                                         SSN
I hereby make application or request renewal for the following credit:

                                                          FINANCIAL CONDITION
                                                            Dollars                                                                Dollars
1. Cash on hand and in banks                                          1. Notes payable to financial institutions - Section A
2. Accounts and notes receivable                                      2. Notes payable to others - Section A
3. Qualified Investments - Section C                                  3. Outstanding credit card debt (not paid within 30
4. Unqualified Securities - Section C                                 4. Outstanding accounts, taxes, and bills
5. Other current assets - itemize                                     5. Notes and contracts owned - Section A
6.                                                                    6. Other current liabilities - itemize
7.                                                                    7.
                Total Current Assets                                - 8.
8. Unlisted securities - Section C                                    Total Current Liabilities                                               -
9. Life insurance - cash value - Section B                            9. Mortgage on primary residence - Section D
10. Mortgages and contracts owned                                     10. Mortgage on secondary residence - Section D
11. Primary residence - Section D                                     11. Other real estate mortgages - Section D
12. Secondary residence - Section D                                   12. Other debts -
13. Other Real Estate Owned - Section D                               13.
14. Personal property                                                 14.
15. Due from friends and relatives                                    15.
16. Other assets - itemize
18.                                                                       Total Liabilities                                                   -
19.                                                                       NET WORTH                                                           -
Total Assets                                                         -    Total Liabilities and Net Worth                                     -

                 ANNUAL SOURCES OF INCOME                                                     PERSONAL INFORMATION
Salary, bonus, and commissions                                            Do you have a will?
Dividends and interest                                                    If yes, provide the name of your Executor.
Real estate income
                                                                          Are you a partner or officer in any other venture?
Other income (Income from alimony, child support
                                                                          If yes, please list:
and maintenance payments need not be revealed unless
                                                                          DO NOT COMPLETE if an application for individual unsecured credit
you wish such income to support a request for credit.)
                                                                          Marital Status
Total                                                                -    Number of Dependents

                      CONTINGENT LIABILITIES                                                 GENERAL INFORMATION
Do you have any contingent liabilities?                                   Are any assets pledged?
If yes, give details.                                                     Are you a defendant in any suits or legal actions?
If yes, as:                                                               At which bank(s) are your personal accounts held?
On leases or contracts?
Any legal claims?                                                         Have you ever taken bankruptcy?
Other special debt?                                                       If yes, please explain.
Amount of contested income tax liens
                                                                   BANK ACCOUNTS
                                                        Names of Banks                                                              Balance on Deposit at Stmt Date
                                                                                                                           Total                                  -

       Due to                    Address             Collateral or Unsecured         Interest Rate Monthly Pymts

                                                        SECTION B - LIFE INSURANCE CARRIED
Names of Companies                                              Amount      Cash Value Amt Borrowed                                            Beneficiaries

                                 SECTION C - STOCKS, BONDS, AND SECURITIES (please attach statements)
       Face Value - Bonds               Description - Indicate those Qualified, Unqualified,
                                                                                                Cost                                                    Market Value
       No. of Shares - Stock             not registered in your name      or Unlisted*

      *Qualified - retirement accounts, IRAs, etc.           Unqualified - stocks, bonds, and mutual funds.     Unlisted - not listed on an organized exchange.

                                                             SECTION D - REAL ESTATE OWNED
        Description and in                                                                                            Balance Owed - Mortgage or Contract
                                                     Value             Rent Rec'd               Amount of Ins
      whose name recorded                                                                                            Amount    Ann Pymt To Whom Payable
Primary residence
Secondary residence

I/we hereby apply for the loan or credit described in this application. I/we certify that I/we made no misrepresentations in this loan application or
in any related documents, that all information is true and complete, and that I/we did not omit any important information. I/we agree that any
property securing the loan or credit will not be used for any illegal or restricted purpose. Lender is authorized to verify with other parties and to
make any investigation of my/our credit, either directly or through any agency employed by Lender for that purpose. Lender may disclose to any
other interested parties information as to Lender’s experiences or transactions with my/our account. I/we understand that Lender will retain this
application and any other credit information Lender receives, even if no loan or credit is granted. These representations and authorizations extend
not only to Lender, but also to any insurer of the loan and to any investor to whom Lender may sell all or any part of the loan. I/we further
authorize Lender to provide to any such insurer or investor any information and documentation that they may request with respect to my/our
The undersigned certifies that all parts of this document and the information inserted therein have been carefully read and are true and correct.

Signature                                                                                                          Date

Signature                                                                                                          Date

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