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PERSONAL FINANCIAL STATEMENT

 

Date: ______________________

Submitted To: _______________

PERSONAL INFORMATION

Applicant's Name _____________________________________________________

Employer _____________________________________________________

Employer's Address _____________________________________________________

Business Phone Number _____________________________________________________

Number of Years with Employer _____________________________________________________

Title/Position _____________________________________________________

Name of Previous Employer & Position (if with current employer less than 3 years) _____________________________________________________

Number of Years with Previous Employer_________________________________

Home Address _____________________________________________________

Home Phone _____________________________________________________

Social Security No. _____________________________________________________

Date of Birth _____________________________________________________

 Co-Applicant's Name_____________________________________________

Employer _____________________________________________________

 Employer's Address _____________________________________________________

Business Phone Number _____________________________________________________

Number of Years with Employer _____________________________________________________

Title/Position _____________________________________________________

Name of Previous Employer & Position (if with current employer less than 3 years) _____________________________________________________

Number of Years with Previous Employer_________________________________

Home Address _____________________________________________________

Home Phone _____________________________________________________

Social Security No. _____________________________________________________

Date of Birth _____________________________________________________

CASH INCOME & EXPENDITURES STATEMENT

FOR YEAR ENDED ____________ 

ANNUAL INCOME AMOUNT ($)

Salary (applicant) _________________________________ 

Salary (co-applicant) _______________________________ 

Bonuses & Commissions (applicant) ___________________ 

Bonuses & Commissions (co-applicant) _________________ 

Rental Income ____________________________________ 

Interest Income ___________________________________ 

Dividend Income __________________________________ 

Capital Gains ____________________________________ 

Partnership Income ________________________________ 

Other Investment Income ___________________________ 

Other Income (list) ________________________________ 

 Total Income $___________

Are any significant changes expected in the next 12 months? [ ] Yes [ ] No

(If yes, attach information.)

** Income from alimony, child support, or separate maintenance income need not be revealed if the applicant or co-applicant does not wish to have it considered as a basis for repaying this obligation.

ANNUAL EXPENDITURES AMOUNT ($)

Federal Income and Other Taxes _____________________ 

State Income and Other Taxes _______________________ 

Rental Payments, Co-op, or Condo Maintenance _________________________ 

Mortgage Payments (Residential) _____________________ (Investment) _____________________ 

Property Taxes (Residential) _________________________ (Investment) _____________________ 

Interests & Principal Payments on Loans _______________ 

Insurance ________________________________________ 

Investments (Including tax shelters) ___________________ 

Alimony/Child Support _____________________________ 

Tuition __________________________________________ 

Other Living Expenses ______________________________ 

Medical Expenses _________________________________ 

Other Expenses (list) _______________________________ 

 Total Expenditures $___________

Balance Sheet as of ____________

ASSETS AMOUNT ($)

Cash in this Bank _______________________________ 

(Including money market accounts, CDs)

Cash in Other Financial Institutions (list) _________________________________________ 

(Including money market accounts, CDs)

Readily Marketable Securities (Schedule A)____________ 

Non-Readily Marketable Securities (Schedule A) ___________________

Accounts and Notes Receivable _______________________________

Net Cash Surrender Value of Life Insurance (Schedule B) __________

Residential Real Estate (Schedule C) ____________________________

Real Estate Investments (Schedule C) ___________________________

Partnerships / PC Interests (Schedule D) _________________________

IRA, Keogh, Profit-sharing & Other Vested Retirement Accounts ___________________________ 

Personal Property (including automobiles) _________________________ 

Other Assets (list): ______________________________ 

 Total $__________

LIABILITIES AMOUNT ($)

Notes Payable to this Bank ________________________ 

Secured _________________________________ 

Unsecured _______________________________ 

Notes Payable to Others _______________________ 

Secured _________________________________ 

Unsecured _______________________________ 

Accounts Payable (including credit cards) ____________ 

Margin Accounts _______________________________ 

Notes Due: Partnership (Schedule D) _______________ 

Taxes Payable _________________________________ 

Mortgage Debt (Schedule C) ______________________ 

Life Insurance Loans (Schedule B) _________________ 

Other Liabilities (list): __________________________ 

 Total Liabilities $__________

 Net Worth $__________

CONTINGENT LIABILITIES

Are you a guarantor, comaker, or endorser for any debt of an individual, corporation, or partnership? [ ] Yes [ ] No $__________

Do you have any outstanding letters of credit or surety bond? [ ] Yes [ ] No $_______

Are there any suits or legal actions pending against you?  [ ] Yes [ ] No $__________

Are you contingently liable on any lease or contract?   [ ] Yes [ ] No $__________

Are any of your tax obligations past due? [ ] Yes [ ] No $__________

What would be your total estimated tax liability if you were to sell your major assets?

 $__________

If yes for any of the above, give details:

SCHEDULE A - ALL SECURITIES (including non-money market mutual funds)

Readily Marketable Securities (including U.S. Governments and Municipalities)*

No. of Shares or Face Value _____________________________________________________

Description _____________________________________________________

Owner(s) _____________________________________________________

Where Held _____________________________________________________

Cost _____________________________________________________

Current Market Value _____________________________________________________

Pledged [ ] Yes [ ] No

No. of Shares or Face Value _____________________________________________________

Description _____________________________________________________

Owner(s) _____________________________________________________

Where Held _____________________________________________________

Cost _____________________________________________________

Current Market Value _____________________________________________________

Pledged [ ] Yes [ ] No

No. of Shares or Face Value _____________________________________________________

Description _____________________________________________________

Owner(s) _____________________________________________________

Where Held _____________________________________________________

Cost _____________________________________________________

Current Market Value _____________________________________________________

Pledged [ ] Yes [ ] No

* If not enough space, attach a separate schedule or brokerage statement and enter totals only.

Non-Readily Marketable Securities (closely held, or restricted stock)

No. of Shares or Face Value _____________________________________________________

Description _____________________________________________________

Owner(s) _____________________________________________________

Where Held _____________________________________________________

Cost _____________________________________________________

Current Market Value _____________________________________________________

Pledged [ ] Yes [ ] No

No. of Shares or Face Value _____________________________________________________

Description _____________________________________________________

Owner(s) _____________________________________________________

Where Held _____________________________________________________

Cost _____________________________________________________

Current Market Value _____________________________________________________

Pledged [ ] Yes [ ] No

SCHEDULE B - INSURANCE

Life Insurance (use additional sheet if necessary)

Insurance Company _____________________________________________________

Face Amount of Policy _____________________________________________________

Type of Policy _____________________________________________________

Beneficiary _____________________________________________________

Cash Surrender Value _____________________________________________________

Amount Borrowed _____________________________________________________

Ownership _____________________________________________________

Insurance Company _____________________________________________________

Face Amount of Policy _____________________________________________________

Type of Policy _____________________________________________________

Beneficiary _____________________________________________________

Cash Surrender Value _____________________________________________________

Amount Borrowed _____________________________________________________

Ownership _____________________________________________________

Insurance Company _____________________________________________________

Face Amount of Policy _____________________________________________________

Type of Policy _____________________________________________________

Beneficiary _____________________________________________________

Cash Surrender Value _____________________________________________________

Amount Borrowed _____________________________________________________

Ownership _____________________________________________________

Disability Insurance Applicant Co-Applicant

Monthly distribution if disabled ________ ___________

Number of Years covered ________ ___________

SCHEDULE C - PERSONAL RESIDENCE & REAL ESTATE INVESTMENTS, MORTGAGE DEBT (majority ownership only)

Personal Residence:

Property Address _____________________________________________________

Legal Owner _____________________________________________________

Purchase Year/Price _____________________________________________________

Market Value _____________________________________________________

Present Loan Balance _____________________________________________________

Interest Rate _____________________________________________________

Monthly Payment _____________________________________________________

Lender _____________________________________________________

Personal Residence:

Property Address _____________________________________________________

Legal Owner _____________________________________________________

Purchase Year/Price _____________________________________________________

Market Value _____________________________________________________

Present Loan Balance _____________________________________________________

Interest Rate _____________________________________________________

Monthly Payment _____________________________________________________

Lender _____________________________________________________

Real Estate Investment:

Property Address _____________________________________________________

Legal Owner _____________________________________________________

Purchase Year/Price _____________________________________________________

Market Value _____________________________________________________

Present Loan Balance _____________________________________________________

Interest Rate _____________________________________________________

Monthly Payment _____________________________________________________

Lender _____________________________________________________

Real Estate Investment:

Property Address _____________________________________________________

Legal Owner _____________________________________________________

Purchase Year/Price _____________________________________________________

Market Value _____________________________________________________

Present Loan Balance _____________________________________________________

Interest Rate _____________________________________________________

Monthly Payment _____________________________________________________

Lender _____________________________________________________

SCHEDULE D - PARTNERSHIPS (LESS THAN MAJORITY OWNERSHIP

FOR REAL ESTATE PARTNERSHIPS)*

Business/Professional (indicate name):

Type of Investment _____________________________________________________

Date of Initial Investment _____________________________________________________

Cost _____________________________________________________

Percent Owned _____________________________________________________

Current Market Value _____________________________________________________

Balance Due on Partnerships: Notes, Cash Call _____________________________________________________

_____________________________________________________

Final Contribution Date _____________________________________________________

Business/Professional (indicate name):

Type of Investment _____________________________________________________

Date of Initial Investment _____________________________________________________

Cost _____________________________________________________

Percent Owned _____________________________________________________

Current Market Value _____________________________________________________

Balance Due on Partnerships: Notes, Cash Call _____________________________________________________

_____________________________________________________

Final Contribution Date _____________________________________________________

*Note: For investments which represent a material portion of your total assets, please include the relevant financial statements or tax returns, or in the case of partnership investments or S-corporations, schedule K-1s.

SCHEDULE E - NOTES PAYABLE

Due to _____________________________________________________

Type of Facility _____________________________________________________

Amount of Line _____________________________________________________

Secured [ ] Yes [ ] No

Collateral _____________________________________________________

Interest Rate _____________________________________________________

Maturity _____________________________________________________

Unpaid Balance _____________________________________________________

Due to _____________________________________________________

Type of Facility _____________________________________________________

Amount of Line _____________________________________________________

Secured [ ] Yes [ ] No

Collateral _____________________________________________________

Interest Rate _____________________________________________________

Maturity _____________________________________________________

Unpaid Balance _____________________________________________________

PLEASE ANSWER THE FOLLOWING QUESTIONS:

1. Income tax returns filed through _______________ (date). Are any returns currently being audited or contested? [ ] Yes [ ] No

If yes, what year(s): ______________________________________________

2. Have (either of) you or any firm in which you were a major owner ever declared

bankruptcy? [ ] Yes [ ] No

If yes, please provide detail: ____________________________________________

3. Have you drawn a will? [ ] Yes [ ] No

If yes, please furnish the name of the executor(s) and year will was drawn: _____________________________________________________

4. Number of dependents (excluding self) and relationship to applicant: _____________________________________________________

5. Have you ever had a financial plan prepared for you? [ ] Yes [ ] No

6. Did you include two years federal and state tax returns? [ ] Yes [ ] No

7. Do (either of) you have a line of credit or unused credit facility at any other

institution(s)? [ ] Yes [ ] No

If so, please indicate where, how much, and name of banker: _____________________________________________________

_____________________________________________________

_____________________________________________________

8. Do you anticipate any substantial inheritances? [ ] Yes [ ] No

If yes, please explain: _____________________________________________________

_____________________________________________________

REPRESENTATIONS AND WARRANTIES

The information contained in the statement is provided to induce you 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 you are 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 you 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 (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 you. 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 you as required above, or if any of the information herein should prove to be inaccurate or incomplete in any material aspect, you may declare the indebtedness of the undersigned or the indebtedness guaranteed by the undersigned, as the case may be, immediately due and payable. You are authorized to make all inquiries you deem necessary to verify the accuracy of the information contained herein and to determine the creditworthiness of the undersigned. The undersigned authorizes any person or consumer reporting agency to give you any information it may have on the undersigned. Each of the undersigned authorizes you to answer questions about your credit experience with the undersigned. As long as any obligation or guarantee of the undersigned to you 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 gives you shall be your property.

_____________ _____________________________________

Date Signature of Applicant

_____________ _____________________________________

Date Signature of Co-Applicant

 

 

Warning:

These forms are provided AS IS. They may not be any good. Even if they are good in one jurisdiction, they may not work in another. And the facts of your situation may make these forms inappropriate for you. They are for informational purposes only, and you should consult an attorney before using them.

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