Personal Financial Statement Form Page 2
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2Do you have any contingent liabilities? If so, describe.
Are you a defendant in any suits or legal actions? _______________
_________________________________________________
Personal bank accounts carried at: ___________________________
_________________________________________________
Have you ever been declared bankrupt? ______ If so, describe on
_________________________________________________
separate sheet.
As endorser, co-maker or guarantor?
$_____________
Are any of your assets held in a Trust? _______ If so, please describe,
On leases or contracts?
$_____________
and provide a copy of the Trust Declaration Page. ________________
________________________________________________________
Legal claims / other special debt
$_____________
________________________________________________________
Amount of contested income tax liens $_____________
PLEASE COMPLETE SCHEDULES BELOW (attach separate sheet if needed)
SCHEDULE A—CASH DEPOSIT ACCOUNTS
ACCOUNT TITLE
FINANCIAL INSTITUTION
ACCOUNT TYPE
AVERAGE BALANCE
ACCOUNT TITLE
FINANCIAL INSTITUTION
ACCOUNT TYPE
AVERAGE BALANCE
$
$
$
$
SCHEDULE B—U.S. GOVERNMENT AND MARKETABLE SECURITIES
NUMBER OF SHARES OR FACE VALUE
ARE THESE
DESCRIPTION
IN NAME OF
MARKET VALUE
(BONDS)
PLEDGED?
$
$
$
SCHEDULE C—LIFE INSURANCE CARRIED, INCLUDING N.S.L.I. AND GROUP INSURANCE
CASH SURRENDER
NAME OF INSURANCE COMPANY
OWNER OF POLICY
BENEFICIARY
FACE AMOUNT OF POLICY
LOANS ON POLICY
VALUE
$
$
$
$
$
$
SCHEDULE D—REAL ESTATE OWNED
AMOUNTS BASED ON % OF OWNERSHIP INTEREST
PERCENT
ADDRESS & TYPE OF PROPERTY
TITLE IN NAME OF
DATE ACQUIRED
ORIGINAL COST
MARKET VALUE
MORT.
PMT.
OWNERSHIP
AMOUNT
AMOUNT
%
$
$
$
$
%
$
$
$
$
%
$
$
$
$
%
$
$
$
$
%
$
$
$
$
SCHEDULE E—NON-MARKETABLE SECURITIES
NUMBER OF
ARE THESE
DESCRIPTION
IN NAME OF
SOURCE OF VALUE
VALUE
SHARES
PLEDGED?
$
$
SCHEDULE F—NOTES PAYABLE (OTHER THAN REAL ESTATE)
NAME & ADDRESS OF LENDER
SECURED/UNSECURED?
ORIGINAL DATE
HIGH CREDIT
CURRENT BALANCE
PMT AMT
$
$
$
$
$
$
$
$
$
SCHEDULE G—BANKS OR FINANCE COMPANIES WHERE CREDIT HAS BEEN OBTAINED
SECURED /
NAME & ADDRESS OF LENDER
CREDIT IN THE NAME OF
ORIGINAL DATE
HIGH CREDIT
CURRENT BALANCE
PMT AMT
UNSEC?
$
$
$
$
$
$
$
$
$
THE INFORMATION CONTAINED IN THIS STATEMENT IS PROVIDED FOR THE PURPOSE OF OBTAINING OR MAINTAINING CREDIT WITH YOU ON
BEHALF OF THE UNDERSIGNED, OR PERSONS, FIRMS OR CORPORATIONS IN WHOSE BEHALF THE UNDERSIGNED MAY EITHER SEVERALLY
OR JOINTLY WITH OTHERS, EXECUTE A GUARANTY IN YOUR FAVOR. EACH UNDERSIGNED UNDERSTANDS THAT YOU ARE RELYING ON THE
INFORMATION PROVIDED HEREIN (INCLUDING THE DESIGNATION MADE AS TO OWNERSHIP OF PROPERTY) IN DECIDING TO GRANT OR
CONTINUE CREDIT. EACH UNDERSIGNED REPRESENTS AND WARRANTS THAT THE INFORMATION PROVIDED IS TRUE AND COMPLETE AND
THAT YOU MAY CONSIDER THIS STATEMENT AS CONTINUING TO BE TRUE AND CORRECT UNTIL A WRITTEN NOTICE OF A CHANGE IS GIVEN
TO YOU BY THE UNDERSIGNED. YOU ARE AUTHORIZED TO MAKE ALL INQUIRIES YOU DEEM NECESSARY TO VERIFY THAT ACCURACY OF
THE STATEMENTS MADE HEREIN, AND TO DETERMINE MY/OUR CREDITWORTHINESS. YOU ARE AUTHORIZED TO ANSWER QUESTIONS
ABOUT YOUR CREDIT EXPERIENCES WITH ME/US.
Signature (Individual)
Dated
Signature (Other Party)
Dated
Revised 1-7-08 DJS
Page 2
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