Personal Financial Statement

Name
Date of Birth
Date of Financial Statement
Email

Cell Phone#
SSN
Street Address
City
State
Zip Code
Home Phone#
Own Home
Renting
Other
Mortgage Payment or Rent
Name & Address of Employer
Title/Position
Length of Employment
Business Phone #
 
Name of Spouse
Date of Birth
Social Security Number
# of Dependants
Name & Address of Employer
Title/Position
Length of Employment
Business Phone #

If married, you may apply for a separate account. If you are married, complete all information for yourself and your spouse. You do not have to list spouse's separate property unless this is an application for a joint account. Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.


List of Assets Amount   List of Liabilities Amount Owed Monthly Payment
Cash in Capon Valley Bank   Income Taxes Payable
Cash in other institutions (list)
  Other Taxes Payable
  Charge Cards Payable (Schedule 4)
  Installment Loans (Schedule 4)
  Loans on Life Insurance
Stocks & Bonds Owned (Schedule 1)   Loans on Stocks & Bonds
IRA / Keogh / Pension Amounts  
Accounts / Notes Receivable (Schedule 2)  
Deeds of Trusts Owned (Schedule 2)  
Real Estate Market Value(s) (Schedule 3)   Real Estate Indebtedness (Schedule 3)
Other Investments / Partnerships   Other Liabilities (List)
Automobiles
 
  Total Payments
Personal Property   Total Liabilities
Other Assets (attach detail)   Net Worth (Assets-Liabilities)
Total Assets:    Total Liabilities + Net Worth
 
Annual Income Amount   Annual Expenses Amount   Contingent Liabilities Amount
Applicant Salary   Interest Expense   As an Endorser
Spouse's Salary   Property Taxes   As a Guarantor
Dividend / Bond Income   Income & Other Taxes   As a Co-signer
Interest Income   Mortgage Payments/Rent   On Damage Claims
Rental Income   Credit Card Payments   Letters of Credit
Other (Detail)
  Loan Payments   Other (Detail)
  Insurance  
  Alimony, Child Support  
  Other (Detail)
 
   
Total Income:      Total Expenses:      Total Liabilities:   
 

General Information - If you are married, these questions apply to both you and your spouse.

Are any assets held in Trust?   Yes   No
Are any assets pledged or debts secured except as shown?   Yes   No
Have you ever had a repossession?   Yes   No
Have you ever had a bankruptcy or had a judgment against you?   Yes   No  If yes, what year?
Have you ever been a principal or guarantor of a firm that declared bankruptcy?   Yes   No  If yes, what year?
Are you a party to any claim or law suit?   Yes   No
Has there been an IRS audit in the past 3 years?   Yes   No
If yes, has the audit been settled?   Yes   No
If yes to any of the above, please explain.  

Schedule 1: Marketable Securities:

Indicate: [J] for joint with spouse  [O] for joint with other than spouse [A] for applicant's separate property  [S] for spouse's separate property

Are any of your Securities Restricted? Yes No

Do you own 10% or more of the outstanding stock of any company? Yes No

How Held # of Shares or Bond Amount Description Title In Name Of Pledged Present Market Value
Total $


Schedule 2: Notes Receivable - Mortgage & Deed of Trust Owned

Indicate: [J] for joint with spouse  [O] for joint with other than spouse [A] for applicant's separate property  [S] for spouse's separate property

How Held Name of Debtor Collateral Date of Note Monthly Payment Maturity Date Unpaid Balance
  Total $
 

Schedule 3: Real Estate Holdings - Mortgages or Liens

Indicate: [J] for joint with spouse  [O] for joint with other than spouse [A] for applicant's separate property  [S] for spouse's separate property
Indicate Type:  [SD] for Single Dwelling  [MD] for Multiple Dwelling or  [C] for Commercial/Industrial

How Held Type Property Address a] Mrkt. Value
b] Orig. Cost
a] Date Purchased
b] % Owned
Name of Lender a] 1st Mortgage
b] 2nd Mortgage
Monthly Payment







 






















































    Total Owed
Total Pmts


Schedule 4: Credit Cards And Loans Payable

Name of Creditor Monthly Payment Current Balance Name of Creditor Monthly Payment Current Balance
Totals   $ $ Totals   $ $


I certify that all information provided by me herein, including attachments (s) is true, correct and complete. I authorize Capon Valley Bank to make whatever inquiries about me you deem necessary and appropriate for the purpose of evaluating my credit, including obtaining credit reports and contacting my employer. I also authorize Capon Valley Bank to provide credit information about its credit experience with me to other creditors and credit reporting agencies. I authorize the Bank to obtain address information from the Department of Motor Vehicles. I agree to provide any further information the Bank might require to process my application.


Please check this box to state that you agree to the above terms and conditions.




Applicant's Signature

Date

Spouse's Signature
(only if applying for joint credit)

Date