PERSONAL FINANCIAL STATEMENT DATE: NAME: SOCIAL SECURITY #: ADDRESS:
AGE:
TELEPHONE #: PREVIOUS ADDRESS (if above is less than 5 years) SPOUSE’S NAME: SOCIAL SECURITY #:
PREVIOUS EMPLOYER TELEPHONE #:
AGE:
ASSETS CASH IN BANK CASH IN BANK ACCOUNTS RECEIVABLE
EMPLOYED BY: YEARS: POSITION: EMPLOYER TELEPHONE #: If employed less than one year, previous employer:
SPOUSE’S EMPLOYER: POSITION: EMPLOYER TELEPHONE #
YEARS:
LIABILITIES $ $ $ $
STOCKS & BONDS (Sch B) NOTES RECEIVABLE - GOOD CASH SURRENDER VALUE LIFE INSURANCE AUTOS YEAR/MAKE
$ $ $ $ $ $
REAL ESTATE (Sch A) OTHER ASSETS (describe) 1. 2. 3. 4. TOTAL ASSETS
$ $ $ $ $
NOTES PAYABLE
$
ACCOUNTS PAYABLE
$
TAXES PAYABLE
$
CONTRACTS PAYABLE
$
OTHER PAYABLE
$
REAL ESTATE LOANS (Sch A) OTHER LIABILITIES (describe) 1. 2. 3. 4. TOTAL LIABILITIES
$ $ $ $ $ $
ANNUAL INCOME SALARY SALARY (wife or husband) SECURITIES INCOME RENTALS OTHER INCOME (describe) 1. 2 3. 4. TOTAL INCOME
$ $ $ $ $
ANNUAL EXPENDITURES REAL ESTATE PAYMENT(S) $ RENT $ INCOME TAXES $ INSURANCE PREMIUMS $ OTHER (describe - include installment payments other than real estate) 1. $ 2. $ 3. $ TOTAL EXPENDITURES $
LESS TOTAL EXPENDITURES NET CASH INCOME
$ $
(exclusive of ordinary living expenses)
$ $ $ $
Give details of any contingent liability as endorser or guarantor. (If necessary, use separate sheet.)
Do you do business with any other bank?
If so, give details.
Have you ever filed any petition under the Bankruptcy Act? Are any of the assets listed on this statement held under a Trust Agreement? [ ] Yes [ ] No Have your income Tax Returns ever been questioned by the Internal Revenue Service?
If so, most recent year.
PERSONAL FINANCIAL STATEMENT Are any encumbered assets or debts secured except as indicated?
Do you have any other business connections?
If so, give details.
Are there any judgments against you?
Any pending?
Have you made a will?
SCHEDULE A - REAL ESTATE LOCATION & TYPE OF IMPROVEMENT
# of dependents
TITLE IN NAME OF
SCHEDULE B - STOCKS AND BONDS NUMBER OF SHARES AMOUNT OF BONDS
ESTIMATED VALUE
AMOUNT OWING
$
$
$
$
$
$
$
$
DESCRIPTION
CURRENT MARKET ON LISTED
COMPANY: COMPANY: COMPANY: COMPANY:
ESTIMATED VALUE ON UNLISTED
$
$
$
$
$
$
$ If additional space is needed for Schedule A and/or Schedule B, list on a separate sheet and attach.
INSURANCE LIFE INSURANCE $ AUTO INSURANCE PUBLIC LIABILITY COMP PERSONAL LIABILITY
TO WHOM PAYABLE
$
BENEFICIARY: YES/NO YES/NO
(circle one) (circle one)
The undersigned certifies that the above statement (or in lieu thereof, the attached statement as the case may be) and supporting schedules, both printed and written, give a full, true, and correct statement of the financial condition of the undersigned as of the date indicated.
Date Signed
Signature
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