Personal Financial Statement

Financial Condition as of Requested Loan Officer or Branch (if known)

Individual Financial Statement Joint Financial Statement

Applicant

Name Address City State Zip Code Birth Date Social Security Number Primary Phone Number Secondary Phone Number Email Address Employer Position (Title) Years

Co-Applicant

Name Address City State Zip Code Birth Date Social Security Number Home Phone Number Office Phone Number Email Address Employer Position (Title) Years

Assets and Liabilities

Cash on Hand

Name of Financial Institution Type of Account Account Balance

Total

Retirement Accounts

Name of Financial Institution Type of Account Account Balance

Total

Marketable Securities Owned

Description Brokerage Firm / Financial Institution Number of Shares Price / Share Current Market Value

Total

Life Insurance

Insurance Company Insured Beneficiary Face Value Cash Value Loans

Total

Investments in Closely Held Companies

Description % Ownership Book Value Current Market Value

Total

Notes Payable

Lender Balance Outstanding Payments Interest Rate Maturity

Balance Outstanding Total Payments Total

Real Estate

Location and Type of Property Purchase Price Original Amount Borrowed Current Amount Owed Payment Amount Income Appraised of Estimated Value / Source

Total Amount Owed (for all properties) Total Payment Amount (for all Properties) Total Income (for all properties) Total Appraised or Estimated Value (of all properties)

Accounts Payable (these amounts should not be previously listed)

Account Payable

Whom the funds are OWED to Amount Owed

Total Amount Owed

Auto, Consumer or Unsecured Loans

Year Make Model Mileage Registered To Bank Amount Owed Payment Value

Amount Owed Total Value Total Total of Payments

Any other Assets not previously listed

Asset

Asset Current Value of Asset

Total

Notes RECEIVABLE or Accounts RECEIVABLE

Note RECEIVABLE

Who Owes YOU How much they owe YOU

Total Notes or Accounts Receivable (these are funds OWED to you)

Assets and Liabilities Summary

Assets

Cash on Hand Total Retirement Accounts Total Marketable Securities Total Cash Value Life Insurance Total Investments in Closely Held Companies Total Auto, Consumer or Unsecured Loans Value Total Notes or Accounts Receivable Total Real Estate Appraised Value or Estimated Value Total Any Other Assets Total Total Assets

Liabilities

Auto, Consumer or Unsecured Loans Amount Owed Total Notes Payable Balance Outstanding Total Real Estate Amount Owed Total Accounts Payable Amount Owed Total Total Liabilities

Net Worth

Annual Personal Cash Flow

Income

All income should be listed as an Annual Amount.

If 'Other Income' is choosen alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for paying this obligation.

Income Type Amount Co-Applicant's Amount

Applicant's Total Co-Applicant's Total Total Joint Income

Expenses / Payments

All expenses should be listed as an Annual Amount

Expenses / Payments Type Combined Amount

Total Expense / Payments

Annual Personal Cash Flow Totals

Total Income Total Expenses / Payments Surplus Income

Total Joint Income Total Expenses / Payments Surplus Income

Please answer the following:

Have you ever filed for bankruptcy? Yes No

If yes, please explain

Are you a co-maker, endorser, or guarantor of any other person's debt? Yes No

Amount

Are you presently the party to any form of litigation? Yes No

If yes, please explain

Are there any tax liens presently outstanding against you or your property? Yes No

Amount

Have you executed a valid will? Yes No

If so, name of administrator of will

Do you have any contingent liabilities? Yes No

If yes, Please list the amount ($)

Endorsement

The information contained in this statement is provided to induce you to extend or to continue the extension of credit to the undersigned or to others upon the guaranty of the undersigned. The undersigned acknowledges and understands that you are relying on the information provided herein in deciding to grant or continue credit or to accept a guaranty thereof. Each of the undersigned represents, warrants and certifies that (1) the information provided herein is true, correct and complete and gives a correct and complete showing of the financial condition of the undersigned, (2) the undersigned has no liabilities direct, indirect or contingent except as set forth in this statement, and (3) legal and equitable title to all assets listed herein is in the undersigned's sole name, except as may be herein otherwise noted. Each of the undersigned agrees to notify you immediately and in writing of any change in name, address, or employment and of any material adverse change (1) in any of the information contained in this statement or (2) in the financial condition of any of the undersigned or (3) in the ability of any of the undersigned to perform its (or their) obligations to you. In the absence of such notice or a new and full written statement, this should be considered as a continuing statement and substantially correct. You are authorized to make all inquires you deem necessary to verify the accuracy of the information contained herein, and to determine the credit-worthiness of the undersigned and the undersigned hereby authorizes all persons of whom you make such inquires to respond thereto in full. Each of the undersigned authorizes you to answer questions about your credit experience with the undersigned. If this financial statement is created as or converted into an electronic format, I consent to the use of electronic records and signatures as defined by the federal and/or state electronic transaction laws. I agree if the financial statement is delivered to the Lender as an electronic record or facsimile transmission with my electronic signature, it will be as effective, enforceable and valid as if a paper version of the financial statement were delivered and signed by me in writing.

Signed by (Applicant) Date Signed

Signed by (Joint Applicant) Date Signed