Personal Financial Statement

Date of Financial Statement

Are you completing as an individual or joint? Individual Joint

1st Indivdual

First Name Middle Initial Last Name Suffix Social Security Number Birth Date Home Address City State Zip Code Work Phone Number Home Phone Number E-mail Address Please do NOT email me important news and updates.

Housing Status

Housing Status Options Own Rent Other

Explain Monthly Mortgage or Rent Payment Monthly Mortgage or Rent Payment

Employment

Employment Status Employed / Self Employed Not Employed

Name of Employer / Business Employer / Business Address City State Zip Code Employer / Business Phone Number

Please Explain

2nd Individual

Employment

Employment Status Employed / Self Employed Not Employed

Name of Employer / Business Employer / Business Address City State Zip Code Employer / Business Phone Number

Please Explain

Assets

Schedule 1: Cash & Deposits

Personal Cash and in Banks Business Cash and in Banks Total

Schedule 2: Marketable Securities

Marketable Securities

Title In Name of Description Amount Title In Name of Description Amount Title In Name of Description Amount

Total Present Market Value

Schedule 3:Net Worth of Businesses Owned

Name of Company Ownership Total Assets Total Liabilities

Net Worth

Schedule 4: IRA / Retirement / Pension Amounts

Description IRA / Retirement / Pension Amounts

Total Present Market Value

Schedule 5: Real Estate Holdings - Mortgages or Liens

Mortgage or Lien

Property Address Real Estate Market Value(s) How Held Name of Lender Property Type Date Purchased First Mortgage Second Mortgage Monthly Payment Original Cost Percentage Owned

Total Monthly Payment Total Owed

Schedule 6: Other Accounts

Account Name	Total Value
Account Name	Total Value

Schedule 7: Automobiles

Description	Total Value
Description	Estimated Value

Schedule 8: Additional/Other Assets

Other Investments / Partnerships Additional Personal Property Other Assets (attach detail)

Liabilities

Schedule 9: Credit Cards And Loans Payable

*Excludes any Mortgage debt

Credit Card or Loan Payable

Name of Creditor	Monthly Payment	Current Balance
Name of Creditor	Monthly Payment	Current Balance

Total Monthly Payment Total Current Balance

Other Liabilities

Description	Amount Owed	Monthly Payment
Description	Amount Owed	Monthly Payment

Liability	Amount Owed
Income Taxes Payable	Income Taxes Payable
Other Taxes Payable	Other Taxes Payable
Loans on Life Insurance	Loans on Life Insurance
Other Real Estate Debt	Real Estate Debt

Annual Income

1st Indivdual 2nd Individual Dividend / Bond Income Interest Income Rental Income Alimony Income Child Support Income

Will the Alimony & Child Support Income continue for the next 5 years? Yes No

Please Explain

Other Income

Description	Annual Total
Description	Annual Total

Total Annual Income:

Annual Expenses

Interest Expense Property Taxes Income & Other Taxes Mortgage Payments/Rent Credit Card Payments Loan Payments Insurance Alimony & Child Support

Other Expenses

Description	Annual Total
Description	Annual Total

Total Annual Expenses:

Contingent Liabilities

Description	Total Amount
Description	Total Amount

Total Contingent Liabilities

Liability / Assets/ Net Worth

Assets Liabilities Monthly Payments Net Worth (Assets - 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

Please Explain

Have you ever had a repossession? Yes No

Please Explain

Have you ever had a bankruptcy or had a judgment against you? Yes No

What year? Please Explain

Have you ever been a principal or guarantor of a firm that declared bankruptcy? Yes No

What year? Please Explain

Are you a party to any claim or lawsuit? Yes No

Please Explain

Has there been an IRS audit in the past 3 years? Yes No

Please Explain

If yes, has the audit been settled? Yes No

Please Explain

Endorsement

I certify that all information provided by me herein, including attachments (s) is true, correct and complete. I authorize Bank Name 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 Bank Name 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.

1st Indivdual Signature Date

2nd Individual Signature Date