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 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		List of Liabilities	Amount Owed	Monthly Payment
Cash in The Citizens National 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 - 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: [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	$	$

I certify that all information provided by me herein, including attachments (s) is true, correct and complete. I authorize The Citizens National 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 The Citizens National 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 1808.21 of the California 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