Confidential Financial Statement

 
*As of: , 20
 
*Name *Social Security No.
*Employer *How Long
*Home Address *Phone
*How Long *Occupation/Position
*Business Address *Phone
*Spouse's Name *No. of Dependents
SECTION A: ASSETS
Cash (Schedule 1)
Marketable Securities (Schedule 2)
Non-Marketable Securities (Schedule 3)
Investment In Partnerships (Schedule 4)
Real Estate - Homestead (Schedule 5)
Real Estate - Other (Schedule 5)
IRA's Keogh & Other Qualified Plans (Schedule 6)
Accounts/Notes Receivable (Schedule 7)
Cash Value Life Insurance (Schedule 8)
Oil & Gas Interests (Schedule 9)
Other Assets  
  Personal Property  
  Automobiles  
  Interests in Trusts  
  Misc.  
*Total Assets  
SECTION B: LIABILITIES
Real Estate/Mortgage Payable (Schedule 5)
Notes Payable (Schedule 10)
Margin Debt Due Brokers (Schedule 2)
Partnership Related Debt (Schedule 4)
Oil & Gas Related Debt (Schedule 9)
Taxes Payable
Credit Card Debt  
Other Liabilities  
 
*Total Liabilities  
*Net Worth (Total Assets Less Total Liabilities)  
*Total Liabilities Plus Net Worth  
SECTION C: CASH INCOME & CASH EXPENSE INFORMATION*
CASH INCOME* *Actual
20		 *Projected
20
Gross Wages or Salaries
Commission, bonuses, etc.
Partnership Draws, etc.
Partnership Distributions
Interest & Dividends
Rental Income
Oil & Gas Income
Other
*Total Cash Income
 
CASH EXPENSES* *Actual
20		 *Projected
20
Real Estate/Mortgage Payments
Regularly Scheduled Principal/Interest Payments
Income Taxes (Sum of a year's periodic payments)
Partnership Contributions
Other Taxes (Real Estate, etc.)
Living Expenses & Misc.
Oil & Gas Expenses
Other Anticipated Payments (Alimony, tuition, etc.)
Other
*Total Cash Expenses
*Net Cash Flow (Cash income less cash expenses)

*Income from 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 all assumptions on Page 4 under Additional Comments and describe any significant expected changes in your cash income or your cash expenses.

In the following statement, the words “I”, “me” and “my” mean anyone signing below. “Your” and “yours” refers to Bank.
I have given you this financial statement and attachments, if any, in order to obtain credit services from you. I understand that you will rely on this information in connection with any decision you make in providing credit or services to me. I warrant and represent to you that this financial statement and any other information I may supply to you is correct, and fully and accurately discloses all of my assets and liabilities including, but not limited to, my contingent liabilities, cash income, and cash expenses as of the date I provide this information to you. All appraisals and similar indicators of value relating to my assets which are available to me as of this date are attached for your review. You may assume that my financial condition is at least as good as shown on this statement until I provide to you another updated financial statement. You may request credit information about me from others including an investigative consumer report and you may request a consumer credit report about me in connection with this statement for credit or services. If I ask you, you will tell me whether or not a consumer credit was requested and will also tell me the name and address of the reporting agency. I give you my permission to obtain additional consumer credit reports and investigative consumer reports without telling me should you update, renew, extend or review my credit or other service arrangements with you. You may also share credit information about me with your affiliates, subsidiaries, parent company, other creditors and others permitted or required by law. I understand that in the event any information contained in this statement is incorrect, false or missing and you incur a loss, you may file a Suspicious Activity Report as may be requested or required by your supervisory agency. I also understand that knowingly providing false or missing information in this financial statement is a federal offense that may subject me to fine or imprisonment or both. (18 USC Section 1014).
ATTENTION: CONTINGENT OBLIGATIONS SCHEDULE MUST BE COMPLETED. IF NONE, WRITE NONE ON THE SCHEDULE
SCHEDULE 1 - Cash
 
Account Name Bank/Branch Name & Address Balance Account Type/Number Pledged
Y or N?
       

SCHEDULE 2 - Marketable Securities
(Stocks, Gov't Issues, Mutual Funds, etc.)
 
Description of Securities Face Value or # Shares Current Market Value Pledged
Y or N?		 Margin Debt Yearly Dividend Income
   

SCHEDULE 3 - Non-Marketable Securities
 
Description of Securities Face Value or # Shares Current Market Value Cost Pledged
Y or N?
       

SCHEDULE 4 - Investments in Partnerships
 
Partnership Name General Limited Other % Owned Cost

Partnership Related Debt
 
Current Market Value Balance Yearly Pay Terms Yearly Distrib. Yearly Contrib.

SCHEDULE 5 - Real Estate
 
Location % Owned Cost:
Date Acquired		 Market Value Org. Bal.
       

Related Debt
 
Current Balance Lienholder Yearly Pay Terms Yearly Rental Income Yearly Rental Expenses
 

SCHEDULE 6 - IRA's, Keogh's & Other Qualified Plans
 
Type % Vested Current Balance Loans Net Value
       

SCHEDULE 7 - Accounts/Notes Receivable
(Including Real Estate)
 
Maker Original Date Original Amount

Present Balance Payments Maturity Purpose & Collateral, If Any
     

SCHEDULE 8 - Cash Value Life Insurance
 
Insurance Company Face Amount Cash Surrender or Loan Value Policy Loan
(If Any)		 Is Policy C/V Assigned? Beneficiary
         

SCHEDULE 9 - Oil and Gas Interests
 
Type of Interest % Owned Valuation
   

Related Debt
 
Balance Lienholder Yearly Pay Terms Yearly Oil & Gas Income Yearly Oil & Gas Expenses
 

SCHEDULE 10 - Notes Payment
(exclude mortgage, partnership, real estate and oil & gas related debt)
 
Name & Address of Financial Institution Purpose Original Date Original Amount

Balance Maturity Yearly Pay Terms Collateral
   

SCHEDULE 11 - Contingent Obligations
 
Instructions: State Total Amount By Type of Liability and Describe
A. As Guarantor or Endorser $ E. Letters of Credit $
B. On Leases or Contracts $ F. Future Capital Contributions $
C. For Legal Claims or Judgments $ G.   $
D. Income Tax Claim or Dispute $ *Total A - G $

Describe A-G Above Beneficiary Party Amount Obligated and
When Obligated		 Purpose Or
Explanation		 Maturity Or
Expiration Date

INSURANCE
  Auto   Home/Real Estate
Insurance Co. Insurance Co.
Policy No. Policy No.
Coverage Coverage
   
   
Agent Name Agent Name
Phone # Phone #
 
Name of Your Personal Attorney   

* 1. Are you a defendant in any suits or legal actions?    No    Yes
 
  If yes, describe below under additional comments.
 
* 2. Income tax returns filed through (date)   
 
* 3. Are any returns being audited or contested?     No    Yes
 
  If yes, what year(s)?   
 
* 4. Have you drawn a will?    No    Yes
 
  If yes, year drawn?       Executor/trix   
 
* 5. Do you have a line of credit or unused line of credit at any other institution?    No    Yes
 
  If yes, indicate how much and where.   
 
* 6. Have you ever filed a petition in bankruptcy or has one been filed involuntarily against you?    No    Yes
 
  If yes, describe below under additional comments.
 
* 7. Are you an Executive Officer, Director, or Principal Shareholder of a bank?    No    Yes
 
  If yes, name bank.   

ADDITIONAL COMMENTS
 

* Indicates a required field.

SIGNATURE:                                                                      DATE:
SIGNATURE:                                                                      DATE: