Personal Financial Statement
Date of Financial Statement
Name
 Date of Birth
 Social Security Number
Email
 Cell Phone #
 Home Phone #
Street Address
 City
State
 Zip Code
Own Home Renting Other
If Other, Explain
 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
Cash in The Bank
Cash in other institutions (list)

Stocks & Bonds Owned (Schedule 1)
IRA / Keogh / Pension Amounts
Accounts / Notes Receivable (Schedule 2)
Deeds of Trusts Owned (Schedule 2)
Real Estate Market Value(s) (Schedule 3)

Other Investments / Partnerships
Automobiles
Personal Property
Other Assets (attach detail)
Total Assets
 

List of Liabilities		 Amount
Owed		 Monthly
Payment
Income Taxes Payable

Other Taxes Payable

Charge Cards Payable (Schedule 4)
Installment Loans (Schedule 4)
Loans on Life Insurance
Loans on Stocks & Bonds

Real Estate Indebtedness (Schedule 3)
Other Liabilities (List)




Total Payments
Total Liabilities
Net Worth (Assets - Liabilities)
Total Liabilities + Net Worth


Annual Income Amount
Applicant Salary
Spouse's Salary
Dividend / Bond Income
Interest Income
Rental Income
Other (Detail)


Total Income:
 
Annual Expenses Amount
Interest Expense
Property Taxes
Income & Other Taxes
Mortgage Payments/Rent
Credit Card Payments

Loan Payments
Insurance
Alimony, Child Support
Other (Detail)
Total Expenses:
 
Contingent Liabilities Amount
As an Endorser
As a Guarantor
As a Co-signer
On Damage Claims
Letters of Credit
Other (Detail)


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 How Held: [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 How Held: [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 How Held: [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 [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
Payments


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 Fiserv 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 Fiserv 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 Section XXXX.XX of the State Vehicle Code. I agree to provide any further information the Bank might require to process my application.



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