Personal Financial Statement

Are you applying as an individual or with a co-applicant?


How would you prefer to be contacted?

Housing Status

Housing Status Options
Monthly Mortgage or Rent Payment includes Taxes and Insurance


Employment Status


How would you prefer to be contacted?

Housing Status

Housing Status Options
Monthly Mortgage or Rent Payment includes Taxes and Insurance


Employment Status


Other Accounts

Account Name Total Value


Description Total Value

Additional/Other Assets


Liability Amount Owed Monthly Payment
Income Taxes Payable
Other Taxes Payable
Charge Cards Payable (Schedule 4)
Installment Loans (Schedule 4)
Loans on Life Insurance
Real Estate Debt (Schedule 3) / Mortgages

Loans on Stocks & Bonds

Title Amount Owed Monthly Payment

Other Liabilities

Description Amount Owed Monthly Payment

Contingent Liabilities

Other Contingent Liabilities

Description Total Amount

General Information

If you are co-applying, these questions apply to both you and your spouse.

Are there any unsatisfied judgement or legal claims against you?
Are any assets pledged or debts secured except as shown?
Have you ever had a repossession?
Have you ever had a bankruptcy or had a judgment against you?
Do you have a vested pension or other deferred compensation?
Are you a party to any claim or lawsuit?
Are you an endorser, comaker, or guarantor for another party?
Are you obligated for any federal income tax claim?
Have you filed federal tax return for the most recent year?
Have you paid all related taxes?

Schedule 3: Real Estate Holdings - Mortgages or Liens

Mortgage or Lien

Monthly Payment includes Taxes and Insurance

Schedule 4: Credit Cards And Loans Payable

Credit Card or Loan Payable

Name of Creditor Monthly Payment Current Balance


This Statement of Financial Condition is presented for the purpose of procuring and maintaining credit in any form whatsoever with United Savings Bank (the "Bank"). Philadelphia, PA. The undersigned hereby certify(ies) to United Savings Bank that this statement is a true statement of his/her/their financial condition. The information contained in this statement is provided to induce United Savings Bank (the "Bank") to extend or to continue the extension of credit to the undersigned or to other upon the surety of the undersigned. The undersigned acknowledge and understand that the Bank is relying on the information provided herein in deciding to grant or continue credit or to accept a surety thereof. Each of the undersigned represents, warrants and certified that the information provided herein is true, correct and completed. Each of the undersigned agrees to notify the Bank immediately and in writing of any change in name, address, or employment and of any material adverse change (1) in any of the information contained in this statement or (2) in the financial condition of any of the undersigned or (3) in the ability of any of the undersigned to perform its (or their) obligations to the Bank in the absence of such notice or a new and full written statement, this should be considered as a continuing statement and substantially correct. United Savings Bank is authorized to make all inquiries the Bank deems necessary to verify the accuracy of the information contained herein, and to determine the credit-worthiness of the undersigned. Each of the undersigned authorizes United Savings Bank to answer questions about United Saving Bank's credit experience with the undersigned. The undersigned understand that the Bank will retain this statement and information contained therein whether or not credit is extended.

I/We fully understand that it is a FEDERAL CRIME, punishable by FINE or IMPRISONMENT, or both, to knowingly make any false statements concerning any of the above facts.