Personal Financial Statement Template
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1
2PERSONAL FINANCIAL STATEMENT
As of ______________________ , ______________
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 guaranty on the loan.
Name
Business Phone
Residence Address
Residence Phone
City, State, & Zip Code
Business Name of Applicant/Borrower
ASSETS
LIABILITIES
(Omit Cents)
(Omit Cents)
$ _________________
Cash on hand & in Banks..................................
$ _________________
Accounts Payable..............................................
$ _________________
Saving Accounts................................................
$ _________________
Notes Payable to Banks and Others.................
(Describe in Section 2)
IRA or Other Retirement Account......................
$ _________________
$ _________________
Installment Account (Auto)................................
Accounts & Notes Receivable...........................
$ _________________
Mo. Payments
$_____________
Life Insurance-Cash Surrender Value Only.......
$ _________________
$ _________________
Installment Account (Other)...............................
(Complete Section 8)
Mo. Payments
$_____________
Stocks and Bonds.............................................
$ _________________
$ _________________
Loan on Life Insurance......................................
(Describe in Section 3)
$ _________________
Mortgages on Real Estate.................................
Real Estate........................................................
$ _________________
(Describe in Section 4)
(Describe in Section 4)
$ _________________
Unpaid Taxes.....................................................
Automobile-Present Value................................
$ _________________
(Describe in Section 6)
Other Personal Property....................................
$ _________________
$ _________________
Other Liabilities..................................................
(Describe in Section 5)
(Describe in Section 7)
Other Assets......................................................
$ _________________
$ _________________
Total Liabilities...................................................
(Describe in Section 5)
$ _________________
Net Worth...........................................................
$ _________________
Total
Total
$ _________________
Section 1. Source of Income
Contingent Liabilities
Salary.................................................................
$ _________________
As Endorser or Co-Maker..................................
$ _________________
Net Investment Income.....................................
$ _________________
Legal Claims & Judgments................................
$ _________________
$ _________________
$ _________________
Real Estate Income...........................................
Provision for Federal Income Tax......................
$ _________________
$ _________________
Other Income (Describe below)*.......................
Other Special Debt............................................
Description of Other Income in Section 1.
*Alimony or child support payments need not be disclosed in "Other Income" unless it is desired to have such payments counted toward total income.
Section 2. Notes Payable to Banks and Others.
(Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)
Original
Current
Frequency
How Secured or Endorsed
Payment
Name and Address of Noteholder(s)
Balance
Balance
(monthly, etc.)
Type of Collateral
Amount
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