Personal Financial Statement

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PERSONAL FINANCIAL STATEMENT

Complete this form for: (1) each proprietor, or (2) each limited partner who owns 20% or more interest and each general partner, or (3) each stockholder owning 20% or more of voting stock, or (4) any person or entity providing a quaranty on the loan.:

Name

Bussiness Phone

Residence Address

Residence Phone

City

State

Zip Code

Bussiness name and applicant/Borrower

Assets

Liabilities

Cash on hands & in Banks

Saving Account

IRA or other retirement Account

Accounts & Notes Receivable

Life Insurance-Cash Surrender Value Only (Complete section 8)

Stocks and Bonds (Describe in Section 3)

Real Estate(Describe in Section 4)

Automobile-Present Value

Other Personal Property(Describe in Section 4)

Other Assets(Describe in Section 5)

Total

Account Payable

Note Payable to Bank and Others

(Describe in Section 2) Instalment Account(Auto)

Mo.Payments

Instalment Account(Other)

Mo.Payments

Loan on Life Insurance

Mortgases On Real Estate(Describe in Section 4)

Unpaid Taxes(Describe in Section 6)

Other Liabilities(Describe in Section 7)

Total Liabilities

Net Worth

Total

Section 1. Source of income

Contingent Liabilities

Salary

Net Investment Income

Real Estate Income

Other Income(Describe below)*

As Endorser or Co-Maker

Legal Claims & Judgments

Provision for Federal Income Tax

Other Special Debt

Describe of Other income in Section 1.

*Alimony or children support payment need to be disclosed in "Other Income unless it is desire to have such payment counted toward total income."

(Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)

Name and Address of Noteholder(s)	Original Balance	Current Balance	Payment Amount	Frequency (monthly,etc.)	How Secured or Endorsed Type of Collateral

Section 3.

No of shares	Name of Securities	Cost	Market Value Quatation/ Exchange	Date Of Quatation/ Exchange	Total Value

Section 4.

	Property A	Property B	Property C
Type of Property
Address
Date Purchased
Original Cost
Present Market Value
Name & Address of Mortgage Holder
Mortgage Account Nummer
Mortgage Balance
Amount of Payment per Month/year
Status of Mortgage

Section 5.

(Describe,and if any is pledged as security, state name and address of lien holder, amount of lien,terms of payment and if delinquent,describe delinquency)

Section 6. Unpaid Taxes.

(Describe in detail,as to type, to whom payable,when due,amount,and to what property, if any,a tax lien attaches.)

Section 7. Other Liabilities.

(Describe in detail.)

Section 8. Life Insurance Held.

(Give face amount and cash surrender value of policies-name of insurance company and beneficiaries)

I authorize Broker/Lender to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify the above and the statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of either obtaining a loan or guaranteeing a loan. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by the U.S. Attorney General (Reference 18 U.S.C. 1001).

Signature:

Date:

Social Security Number:

Signature:

Date:

Social Security Number:

Notes:

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