Personal Financial Statement Template
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1
2PERSONAL FINANCIAL STATEMENT
Bank Name
Name(s) _________________________________________________________________________
Business Phone #
Address __________________________________________________________________________
Residence Phone #
For the purpose of causing you to grant credit to me/us from time to time, either directly or indirectly, or to persons, firms, or corporations for whom I/we may be an endorser or guarantor, I/we
submit the following statement of my/our financial condition of (date) ________________________. I/we agree that if any changes occur which materially reduces my/our means or ability to pay
obligations I/we will promptly give you written notification unless I/we am not indebted to you in any way at the time of such change. So long as I/we am/are indebted to you, or whenever I/we apply
for credit, either directly or indirectly you may rely upon this statement as a continuing statement of my/our financial standing until you are given written notification of such a change. The funds
applied for hereby are to be used for a: ____________________________________________________________________________________________________________________
CHECK ONE: ڤPersonal Purpose
ڤBusiness Purpose
ASSETS
Individual
Joint
LIABILITIES
Individual
Joint
Cash on hand & in banks (checking)
Notes Payable - see Schedule E
CD's & Savings
Banks - secured
U.S. Govt. securities - see Schedule A
Banks - unsecured
Listed securities - see Schedule A
Chattel Mortgages, Liens
Unlisted securities - see Schedule B
Other
Cash value life ins. - see Schedule C
Accounts and bills due
Accounts & Notes Receivable
Due to brokers
— good
Unpaid Real Estate taxes
— doubtful
Unpaid Income Taxes
Real Estate owned - see Schedule D
Mortgages payable on real estate
Automobiles
— see Schedule D
Loans on life insurance policies
Personal Property
Other debts — itemize
Investment in own business*
Other assets — itemize
Total Liabilities
Net Worth
Total Assets
Total Liabilities & Net Worth
SOURCE OF INCOME
PERSONAL INFORMATION
Alimony, child support or maintenance income need not be revealed if you
Business or Occupation _______________________________________
do not wish it to be considered as a basis for repaying this obligation.
Partner or Officer in any other venture? __________________________
Salary
DOB ________________________ DOB ________________________
Bonus and/or commissions
# of Dependents _________ Ages _____________________________
Dividends and/or bond interest
Do you have a will? _______ Name of Executor ___________________
Real Estate income (net)
Do not answer the following question if you are applying for separate
Other income — itemize
unsecured debt.
Married ________
Separated ________
Unmarried ________
Total
GENERAL INFORMATION
CONTINGENT LIABILITIES
Individual
Joint
Social Security Number ______________________________________
Are you defendant in any suits or legal actions? ___________________
As endorser, comaker or guarantor*
_________________________________________________________
On leases or contracts*
Personal bank accounts carried at _____________________________
Letters of Credit
_________________________________________________________
Have you ever taken bankruptcy?
Explain:
Are you liable for any unsatisfied judgments?
Other special debt*
LIST OF BANKS AND FINANCE COMPANIES WHERE CREDIT HAS BEEN OBTAINED
Name
High Credit
Type of Loan
*REMARKS: Please use the following space for any comments or explanations you wish to make.
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