Personal Financial Statement Page 2
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2PERSONAL FINANCIAL STATEMENT
PREPARED FOR
The Arlington Bank
ANNUAL INCOME (As reported on most recent tax return)
Borrower
Co-Borrower
Base Income
$
$
Bonus
$
$
Commissions
$
$
Net Rental Income
$
$
Other Income
$
$
(alimony, child support or separate maintenance
need not be revealed if you do not wish to have it
considered as a basis or repaying this obligation)
TOTAL INCOME
$
0
$
0
SCHEDULE A: REAL ESTATE OWNED
KEY:
STATUS:
PS- Pending Sale
S- Sold
PROPERTY TYPE:
A- Residence B- Multi Family
R- Rental Prop.
D- Develop
C- Commercial D- Farm
L- Long Term Hold O- Other
E- Vacant Land F-Other
Mortgage
Gross Mo.
Monthly
Address of
% of
Market
Income
Mtg. Pmt
Property
Status
Type Ownership
Value
Lender
Balance
1
2
3
4
5
6
Are you a partner, member or officer in any venture? If so, list name, type and location of business, principal partners and percentage of ownership:
List and explain any assets which are pledged or hypothecated in any way:
List and explain any pending legal action:
List any contingent liabilities (as endorser, co-maker or guarantor) not shown on financial statement:
Have you ever declared bankruptcy? Yes __ No __ If yes, please provide details:
ARE YOU A U.S. CITIZEN?
No ___
ARE YOU A U.S. CITIZEN?
Yes ___
No ___
Yes ___
If "no", are you a resident alien?
Yes ___
No ___
If "no", are you a resident alien?
Yes ___
No ___
If "no", are you a non-resident alien?
Yes ___
No ___
If "no", are you a non-resident alien?
Yes ___
No ___
WARNING- PLEASE READ THE FOLLOWING STATEMENT CAREFULLY BEFORE SIGNING THIS FINANCIAL STATEMENT:
The information contained in this financial statement, including all supporting documentation which may be submitted, is provided for the purpose of inducing The Arlington
Bank ("Lender") to grant or continue credit on behalf of the undersigned, or persons, firms or corporations in whose behalf the undersigned may either severally or jointly with
others, execute a note or guaranty in Lender's favor. Each undersigned understands that Lender is relying on the information provided herein in deciding to grant or continue
credit. Each undersigned represents and warrants that the information provided is true and complete and that Lender may consider this financial statement to be true and
correct until written notice of a change is given to Lender by the undersigned. Lender is authorized to make all inquiries it deems necessary to verify the accuracy of the
statements made herein and to determine the credit worthiness of the undersigned. It is a federal crime punishable by fine or imprisonment, or both, to knowingly
make any false statements concerning any of the above provided facts as applicable under the provisions of Title 18, United States Code, Section 1014. The Ohio laws against
discrimination require that all creditors make credit equally available to all creditworthy customers, and that credit reporting agencies maintain separate credit histories on each
individual upon request. The Ohio Civil Rights Commission administers compliance with this law.
Signature
Date
Signature
Date
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