Personal Financial Statement

Applicant

How would you prefer to be contacted?

• Home Phone
• Work Phone
• Email
• Other

Housing Status

• Own
• Rent
• Other:

Employment

• Employed
• Not Employed

Co-Applicant Information

If coapplying, you may apply for a separate account. If you are coapplying, 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.

Co-Applicant Employment

Is the co-applicant employed?

• Employed
• Not Employed

Assets

Other Accounts

Automobiles

Liabilities

Loans on Stocks & Bonds

Other Liabilities

Liability & Asset Totals

Annual Income

Other Income

Annual Expenses

Other Expenses

Contingent Liabilities

Other Contingent Liabilities

General Information

If you are co-applying, 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

Have you ever been a principal or guarantor of a firm that declared bankruptcy?

• Yes
• No

Are you a party to any claim or lawsuit?

• 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

Are any of your securities restricted?

• Yes
• No

Do you own 10% or more of the outstanding stock of any company?

• Yes
• No

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

Schedule 3: Real Estate Holdings - Mortgages or Liens

Schedule 4: Credit Cards And Loans Payable

Endorsement

I certify that all information provided by me herein, including attachments (s) is true, correct and complete. I authorize Edgewater 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 Edgewater 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 and waive the address confidentiality requirements of the State Vehicle Code. I agree to provide any further information the Bank might require to process my application.