Personal Financial Statement

Asterisks (*) denote required fields.

For your convenience, you may use this form if your loan officer requests updated financial information from you. Filling out this form does not constitute a loan application. Please contact your loan officer directly if you wish you apply for an agricultural or commercial loan. If you wish you apply for a mortgage loan, please click this link to be directed to our online application.

This personal financial statement is current as of the following date: *

Please contact your banker if you need assistance with the schedules.

For new financing or refinancing, please complete the information in the "Financing" section below.

Borrower Information

Full Name *
Address *
City *
State *
Zip *
Do you currently own?
Yes No
Do you currently rent?
Yes No
Since
Position/Occupation *
Number of Years
Name of Business *
Address of Business
Residential Phone *
Business Phone
Cell Phone
Email Address *
Marital Status
Married Unmarried Separated
Number of Dependents
Social Security Number
Date of Birth *

Co-Borrower Information (if applicable)

Full Name
Address
City
State
Zip
Do you currently own?
Yes No
Do you currently rent?
Yes No
Since
Position/Occupation
Number of Years
Name of Business
Address of Business
Residential Phone
Business Phone
Cell Phone
Email Address
Marital Status
Married Unmarried Separated
Number of Dependents
Social Security Number
Date of Birth

Assets and Liabilities

Assets Liabilities
Cash, Savings and CD's (Schedule A) $ Short Term and Installment Loans (Schedule H) $
Securities/Investments Owned (Schedule B) $ Credit Accounts and Bills Due (Schedule I) $
Cash Value - Life Insurance
(Schedule C)
$ Insurance Loans (Schedule C) $
Primary Residence (Schedule D) $ Mortgage on Home (Schedule D) $
Other Real Estate (Schedule E) $ Mortgage on Other Real Estate (Schedule E) $
Retirement Accounts (Schedule F) $ Unpaid Taxes $
Business Ventures (Schedule G) $ Other Liabilities (Describe)

$
Automobile (Yr., Make, Model)

$
Contingent Liabilities (Schedule J) $
Personal Property (Describe)

$
Other Assets (Describe)

$
Total Assets $ Total Liabilities $
Net Worth $

 

Annual Income Estimate of Annual Expenditures
Salary, Bonus, and Commissions * $ Mortgage/Rental Payments $
Dividends and Interest $ Real Estate Taxes and Assessments $
Rental and Lease Income (Net) $ Taxes - Federal/State/Local $
Other Party's Income $ Insurance Payments $
Other Income (Income from alimony, child support need not be revealed if you do not choose to rely on it for repayment of this obligation.) $ Other Contract Payments (Car,
Charge Cards, etc.)
$
Alimony, Child Support, Maintenance $
Other Expenditures $
Total $ Total $

Schedule A - Cash, Savings and Certificates of Deposits

Name of Institution Ownership
(Joint, Individual or Trust)
Type of Account
(Checking, Savings, CD)
Amount
$
$
$
$
$
$
$
Total $

Schedule B - Securities/Investments Owned (Stocks, Bonds, Mutual Funds, etc.)

# of Shares or
Bond Amount
Description In Name of Are these Registered,
Pledged, or Held
by Others?
Present Value M = Marketable
N = Nonmarketable
$ M N
$ M N
$ M N
$ M N
$ M N
Total $

Schedule C - Life Insurance

Insured Insurance Company Beneficiary Face Value of Policy Cash Value Loans
$ $ $
$ $ $
$ $ $
Total $ $

Schedule D - Primary Residence Information

Present Market Value of Primary Residence   

$

Name of Creditor Note Date Interest Rate Original Amount Maturity Date Monthly
Payments
Current Balance
of Outstanding
Mortgage
Mortgage % $ $ $
2nd Mortgage % $ $ $
3rd Mortgage % $ $ $
Insurance Company: Agent: Total $

Schedule E - Other Real Estate Owned

Address and
Type of
Property
Name of Creditor % of Ownership Year Acquired Rent Income Purchase Price Interest Rate Monthly Payments Mortgage Balance Current Market
Value of
Property
% $ $ % $ $ $
% $ $ % $ $ $
% $ $ % $ $ $
% $ $ % $ $ $
% $ $ % $ $ $
Insurance Company: Agent: Total $ $

Schedule F - Retirement Plan Schedule: Profit Sharing, IRA and Pension Accounts

% Vested Name of Company Type of Account Distribution Date Manner of Payout
(Annuity, Lump Sum)
Account Balance Loans Against
% $ $
% $ $
% $ $
Total $ $

Schedule G - Mortgages or Liens on Real Estate

Business Venture
in Which You are
a Principal
or Partner
Your Position/Title
in Business
Nature of Business Years in Business Your % of
Ownership
Net Worth
of Business
Present Net Value
of Your Investment
% $ $
% $ $
% $ $
Total $ $

Schedule H - Loans Payable to Banks, Credit Lines and Other Short Term Installments

Name of Creditor Address Collateral (What)
or Unsecured (U)
Repayment Terms Maturity Date Unpaid Balance
$ per $
$ per $
$ per $
$ per $
Total $

Schedule I - Credit Cards/Accounts, Bills Due, Alimony/Child Support, Daycare, etc.

Name of Company Repayment Terms Balance Due
$ per $
$ per $
$ per $
$ per $
Total $

Schedule J - Contingent Liabilities

Business Venture in
Which You are a
Co-Marker, Guarantor,
or Endorser
Name of Creditor Your % of Ownership Co-maker, Guarantor,
or Endorser
Limited or Unlimited Contingent Amount
% $
% $
% $
% $
Total $
Name of Accountant: Name of Attorney:

 

Borrower Co-Borrower
Yes No Yes No
Income tax return filed through what year? *
Are returns currently being audited or contested? What year? *
In the last 7 years, do you have any unsatisfied judgements? In the last ten years, have you been declared bankrupt? *
In the last 7 years, have you had property foreclosed upon or given title or deed in lieu thereof? *
Are you a co-maker, guarantor or endorser on a note? If yes, denote amount: * $
Are you a party in a lawsuit? *
Do you have a will/estate plan in place? When was it last reviewed? *

The undersigned acknowledge and understand that the bank is relying on the information provided herein or continue credit or to accept a guarantee thereof. Each of the undersigned represents, warrants and certifies that the information provided herein is true, correct and complete. Unless the bank is notified of any change, it may continue to rely upon the statement herein as a true, complete and accurate statement. The undersigned authorize any person or consumer reporting agency to give the bank any information it may have on the undersigned. This personal financial statement shall be considered the bank's property.

Date Signed: * Borrower Signature: *
Date Signed: Co-Borrower Signature: