Personal Financial Statement

RETURN TO: Today’s Date is______________2011

Personal Financial Statement of_­­­­­_________________

Name of Applicant

PERSONAL INFORMATION

SECTION 1- INDIVIDAL INFORMATION SECTION 2-SECOND PARTY INFORMATION

APPLICANT’S NAME:	CO-APPLICANT’S:
Employer:	Employer:
Address of Employer:	Address of Employer:
Business Phone: ( )	Years Employed:	Title/Position:	Business Phone: ( )	Years Employed:	Title/Position:
Home Address: City:	State: Zip:	Home Address: City:	State: Zip:
Home Phone: ( )	Social Security No:	Dare of Birth:	Home Phone ( )	Social Security No.	Date of Birth:

SECTION 3- STATEMENT OF FINANCIAL CONDITION AS OF ___________________________________________2011

ASSETS (Do not include Assets of Doubtful Value)	In Dollars (Omit Cents)	LIABILITIES	In Dollars (Omit Cents)
Cash on Hand in Banks			Notes payable to Banks –secured Schedule D
Marketable Securities-Gov’t. Bonds-See Schedule A			Notes payable to Banks - unsecured Sched. D
Non-Marketable Securities-See Schedule. A			Due to Brokers
Securities held by Broker in margin accounts			Amounts payable-secured
Investment Real Estate – See Schedule B			Leases and/or rents
Residential Real Estate – See Schedule B			Amounts Payable including Credit cards
Retirement Plans			Property Taxes due and/or unpaid
Notes Receivable			Unpaid Taxes Federal & State
Cash Held in other Institutions			Unpaid Interest & Principal.
Personal Property			Delinquent accounts
Cash value of Life Insurance - See Schedule C			Judgements
OTHER ASSETS (list them			Real Estate Mortgages Payable-See Shed. B
			OTHER LIABILITIES (list them)
			TOTAL LIABILITIES
			NET WORTH
TOTAL ASSETS			LIABILITIES & NET WORTH

CONTINGENT LIABILITIES YES NO AMOUNT

Are you a Guarantor, Co-Maker, or Endorser for any person or company?   $_________

Do you have any outstanding letters of credit or Surety bonds?   $_________

Are there any suits or legal actions pending against you?   $_________

Are you liable or have a contingent liability on any lease or contract?   $_________

Do you have any tax liability, State or Federal?   $_________

Do you have or ever had any Tax Liens from any governing body?   $_________

Are you obligated to pay child support, alimony or separate maintenance?   $_________

Have any judgements ever been entered against you?   $_________

IF YES TO ANY OF THE ABOVE, GIVE DETAILS: ______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Cash Income & Expenditures for the Year of 2011 (omit cents)

ANNUAL INCOME	AMOUNTS	ANNUAL EXPENDITURES	AMOUNTS
Annual Salary	$	Rental Payments	$
Salary Co-Applicant		Lease Payments
Bonuses and/or Commissions		Mortgage Payments Residential Mortgage Payments Investment Property
Rental Income		Property Taxes all Properties
Interest Income		Federal and State Income taxes
Dividend Income		Insurance (life, medical, property etc.)
Capital Gains Taken		Investments
Partnership Income		Alimony/Child Support
Other Investment Income		Tuition
Other Income Sources (list)		Medical Expenses
		Credit Card payments
		Other Expenses (list separately)
TOTAL INCOME	$	TOTAL EXPENSES	$

No. of Shares Stock or Face value of bonds	DESCRIPTION (Stocks or Bonds)	OWNER(s)	WHERE HELD	COST	CURRENT MARKET VALUE	Pledged YES	Pledged NO
Readily Marketable Securities
							
							
							
							
Non Marketable Securities
							
							
							
							

Schedule B - All Real Estate Owned
Address & Type Of Property	Title in the name of	Date Acquired	Cost	Market Value	Mortgage Maturity	Mortgage Amount Due

Schedule C – Life Insurance Carried, Including N. S.L. I. and Group Insurance
Name of Insurance Company	Policy Owner	Beneficiary	Face Amount	Policy Loans	Cash Surrender Value

Schedule D - Notes Payable
Due To:	Type of Facility	Secured? Yes no	Amount of Line	Interest Rate	Maturity	Unpaid Balance
			
			
			
			

Schedule E – BANKS OR FINANCE COMPANIES WHERE CREDIT HAS BEEN OBTAINED
Name of The Lender	Credit in the name of	Secured or Un-secured	Original date	High Credit	Current Balance

The information contained herein is provided to qualify for the financing that has been requested and for maintaining credit in this connection. Each of the undersigned understands that the lender(s) are relying on this information along with other information in order to qualify for the financing for the entity for which the financing been applied for. The undersigned represents and warrants that the information provided is the truth and is complete and that you may consider this statement as continuing to be true and correct until written notice of a change is given to you by the understand in connection with the financing requested. You are authorized to make all and any inquiries you deem necessary to verify the accuracy of the statements made hereon; and to determine my/our creditworthiness.

Signature ____________________________________________

Signature (second party)_________________________________

Date Signed_____________________ 2011