Personal Financial Statement Form
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1
2PERSONAL FINANCIAL STATEMENT
IMPORTANT: Read these directions before completing the Statement.
If you are applying for individual credit in your own name and are relying on your own income or assets and not the income or assets
of another person as the basis for repayment of the credit requested, complete only Sections 1 and 3.
If you are applying for joint credit with another person, complete all Sections providing information in Section 2 about the joint
applicant.
If you are applying for individual credit, but are relying on income from alimony, child support, or separate maintenance or on the
income or assets of another person as a basis for repayment of the credit requested, complete all sections, providing information in
Section 2 about the person upon whose alimony, support or maintenance payments or income or assets you are relying.
If this statement relates to your guaranty of the indebtedness of other person(s), firm(s) or corporation(s), complete Sections 1 and 3.
To: COAST CENTRAL CREDIT UNION
SECTION 1—INDIVIDUAL INFORMATION (TYPE OR PRINT)
SECTION 2—OTHER PARTY INFORMATION
Name
Name
Residential Address
Residential Address
City, State & Zip
City, State & Zip
Social Security Number
--
--
Social Security Number
--
--
Date of Birth
/
/
Date of Birth
/
/
Position or Occupation
Position or Occupation
Business Name
Business Name
Business Address
Business Address
City, State & Zip
City, State & Zip
H Phone
(
)
-
Bus Phone
(
)
-
H Phone
(
)
-
Bus Phone
(
)
-
SECTION 3—STATEMENT OF FINANCIAL CONDITION:
AS OF: (DATE)
_______ / _______ / _______
ASSETS
LIABILITIES
IN DOLLARS
IN DOLLARS
(Do not include assets of doubtful value)
(Omit cents)
(Omit cents)
Cash with Coast Central Credit Union - Sched A
Revolving debt outstanding
Cash on hand and in Other Fin Inst - Sched A
Unpaid income tax
U.S. Gov’t./Marketable Securities - Schedule B
Other unpaid taxes and interest
Cash Value-Life Insurance—Schedule C
Notes Payable (other than real estate)--Sched F
Real Estate Owned—Schedule D
Real Estate Mortgages Payable—Schedule D
Notes / Loans Receivable
Vehicle/RV loans
Retirement Accounts / IRAs
Other Debts—itemize
Vehicles and RVs
Equipment
Non-marketable Securities—Schedule E
Personal Property
TOTAL LIABILITIES
Other Assets—itemize
NET WORTH
(Total Assets minus Total Liabilities)
TOTAL ASSETS
TOTAL LIABILITIES AND NET WORTH
SOURCES OF INCOME FOR THE YEAR ENDED ___________
PERSONAL INFORMATION
Do you have a will?
If so, name of executor.
Salary, Bonuses and Commissions
$_______________
Are you a partner or officer in any other venture? If so, describe.
Dividends
$_______________
Are you obligated to pay alimony, child support or separate
Real Estate Income
$_______________
maintenance payments?_______ If so, describe.
Other Income
Are any assets pledged other than as described on schedules?
(Alimony, child support, or separate maintenance. Income
need not be revealed if you do not wish to have it considered as a basis for
______ If so, describe.
$_______________
repaying this obligation.)
TOTAL INCOME
$_______________
Income tax settled through (date)
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