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 Co-Applicant
Date of Birth
Social Security Number
# of Dependants
Name & Address of Employer
Title/Position
Length of Employment
Business Phone #

You may apply for a credit extension of financial accomodation individually or jointly with a co-applicant. This statement and any applicable supporting schedules may be completed jointly by both married and unmarried co-applicants if their assets and liabilities are sufficiently joined so that the statement can be meaningfully and fairly presented on a combined basis; otherwise separate statements and schedules are required.


List of Assets Amount   List of Liabilities Amount Owed Monthly Payment
Cash in the Pine Island 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:

  Applicant Co-Applicant
Are any assets held in Trust?   Yes   No Yes   No
Are any assets pledged or debts secured except as shown?   Yes   No Yes   No
Have you ever had a repossession?   Yes   No Yes   No
Have you ever had a bankruptcy or had a judgment against you?   Yes   No 
If yes, what year?
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?
Yes   No 
If yes, what year?
Are you a party to any claim or law suit?   Yes   No Yes   No
Has there been an IRS audit in the past 3 years?   Yes   No Yes   No
If yes, has the audit been settled?   Yes   No Yes   No
Have you made a will?   Yes   No Yes   No
Number of Dependents
(If "None" check None)
     None    None
Marital Status (answer only if this financial statement is provided
in connection with a request for secured credit or applicant
is seeking a joint account with spouse.
  Married
Separated
Unmarried
Married
Separated
Unmarried
       (Unmarried includes single, divorced, widowed)
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

$ $


The foregoing statement, submitted for the purpose of obtaining credit, is true and correct in every detail and fairly shows my/our financial condition at the time indicated. I/we will give you prompt written notice of any subsequent substantial change ini such financial condition occurring before discharge of my/our obligations to you. I/we understand that you will retain this personal financial statement whether or not you approve the credit in connection with which it is submitted. You are authorized to check my/our credit and employment history or any other information contained herein.

THE UNDERSIGNED CERTIFY THAT THE INFORMATION CONTAINED ON THIS FORM
HAS BEEN CAREFULLY REVIEWED AND THAT IT IS TRUE AND CORRECT IN ALL RESPECTS.



Applicant's Signature

Date

Co-Applicant's Signature
(only if applying for joint credit)

Date