Personal Financial Statement

Name:

Home Address:

Email:

Phone:

Cell Phone:

Business Address:

Business Phone:

Instructions

1. Complete the Balance Sheet Section
  1. Complete the appropriate schedules
  2. Total each schedule’s balances & transfer totals to Balance Sheet
  3. Complete the remaining Balance Sheet items
  4. Total Assets, Liabilities, and calculate Net Worth
  5. Complete Contingent Liabilities
2. Sign and date after reviewing financial and credit report statements (please use additional sheets if necessary)

I/We guarantee that the information I/we have given you below is a true and accurate statement of my financial condition as of

Balance Sheet
ASSETS		LIABILITIES
Cash on Hand & in Accounts (Sch. 1)		Accounts Payable
Accounts & Notes Receivable (Sch. 2)		Notes Payable (Sch. 7)
U.S Government Bonds		Mortgages (Sch. 6)
Listed Marketable Stocks & Bonds (Sch. 3)		Installment Loans (Sch. 8)
Unlisted, Non-Liquid Stocks & Bonds (Sch. 4)		Life Insurance Loans
Real Estate (Sch. 5)		Other Liabilities (Details Below)
Life Insurance (Cash Value)
Furniture & Fixtures
Automobiles
IRA,KEOGH & Vested Pension Funds
Other Assets (Detail Below):
		Total Liabilities
		Net Worth
Total Assets		Total Liabilities and Net Worth

Contingent Liabilities

Do you have any contingent liabilities? If so, please describe:

As endorser, co-maker, or guarantor: $

On leases or contracts: $

Amount of contested income tax liens: $

Legal Claims: $

Other Special Debt: $

Schedule 1: Cash Accounts

Depository Institution	In Name Of	Account Type	Balance
1.
2.
3.
4.
5.
6.
			TOTAL

Schedule 2: Accounts and Notes Receivable

Debtor’s Name	Purpose	Monthly Payment (Specify if Principal and/or interest)	Balance
1.
2.
3.
4.
5.
6.
			TOTAL

Schedule 3: Listed Marketable Stocks and Bonds

No. Shares	Issue	Owner	Pledged		Market Value
1.			Yes	No
2.
3.
4.
5.
6.
					TOTAL

Schedule 4: Unlisted, Non-Liquid Stocks and Bonds

No. Shares	Issue	Owner	Validation Method	Value
1.
2.
3.
4.
5.
				TOTAL

Schedule 5: Real Estate

Location & Description	Title In Name Of	Purchase Date	Purchase Price	Market Value
1.
2.
3.
4.
5.
				TOTAL

Schedule 6: Mortgages

Creditors Name	Collateral Position	Original Amount	Monthly Payment (Prin. & / or Int.)	Present Balance
1.
2.
3.
4.
5.
				TOTAL

Schedule 7: Notes Payable

Creditors Name	Purpose	Collateral	Monthly Payments (Specify If Principal Interest, Taxes)	Balance
1.
2.
3.
4.
5.
				TOTAL

Schedule 8: Installment Loans

Creditor’s Name	Purpose	Collateral	Monthly Payment	Balance
1.
2.
3.
4.
5.
6.
				TOTAL

Representation, Warranties, and Authorization

The information contained in this statement is provided to induce the Bank to extend or to continue the extension of credit to the undersigned or to others upon the guarantee 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 guarantee thereof. Each of the undersigned represents, warrants and certifies that the information provided herein is true, correct and complete. 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. If the undersigned fail to notify the Bank as required above, or if any of the information herein should prove to be inaccurate or incomplete in any material respect, the Bank may declare the indebtedness of the undersigned or the indebtedness guaranteed by the undersigned, as the case may be, immediately due and payable.

By signing below, you authorize the Bank to make or have made any credit, employment or investigation inquiry that the Bank determines appropriate for the extension of credit, periodic evaluation of your account or the collection of amounts owed to the Bank on the account, or for any other legitimate purposes associated with the account, including without limitation, obtaining one or more credit reports. This authorization will also apply to the Bank’s agents, affiliates, successors, and assigns. The Bank may furnish information concerning your account to consumer reporting agencies and others who may properly receive the information. If you ask, you will be informed whether a consumer report was requested, and if a report was requested, you will be informed of the name and address of the consumer reporting agency that furnished the report. Each of the undersigned authorizes the Bank to answer questions about your credit experience with the Bank. As long as any obligation or guarantee of the undersigned to the Bank is outstanding, the undersigned shall supply annually an updated financial statement.

This personal financial statement and any other financial or other information that the undersigned give to the Bank shall be the Bank’s property.

NOTICE REGARDING USA PATRIOT ACT: The Bank complies with Section 326 of the USA Patriot Act. This law mandates that we obtain and verify certain information about you, including your name, legal address, date of birth and social security or tax identification number, while processing your account application.

Date: Signature:

Date of Birth:

Social Security Number: