Statement Of Information Form Page 2
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2File No.: ____________________
FORMER MARRIAGE(S)
Please complete the following:
OR
If no former marriages, indicate “NONE” ____________________
Name of former wife: ___________________________________________________________________________________________
Deceased
Divorced
Date: ___________________________
Where: ________________________________
Name of former husband: _______________________________________________________________________________________
Deceased
Divorced
Date: ___________________________
Where: ________________________________
(attach additional page, if necessary)
CHILDREN
_______________________________
__________________
_______________________________
__________________
Name
Date of Birth
Name
Date of Birth
_______________________________
__________________
_______________________________
__________________
Name
Date of Birth
Name
Date of Birth
(attach additional page, if necessary)
Have you ever owned a boat, airplane or any licensed vehicle (other than a car)?
No
Yes
If yes, describe vehicle: __________________________________________________
License Number: _________________
Have you ever filed bankruptcy?
No
Yes
If yes, where: County ___________________________________________________
State: __________________________
Is any portion of the new loan funds to be used for construction?
No
Yes
I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT:
Signature: ________________________________________ Spouse’s Signature: ________________________________________
Home
Bus
Spouse’s
Phone __________________________
Phone ____________________________
Bus Phone _________________________
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Parent category: Legal