Personal Financial Statement Template

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Forward Financial Bank
207 W 6th St.
PO Box 608
Marshfield, WI
54449
+/2146#06
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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 A and
C.
If you are applying for joint credit with another person, complete all Sections providing information in Section B 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 B about the person 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 A and
C.
AMOUNT
REQUESTED
PAYMENT DATE
DESIRED
PROCEEDS OF CREDIT TO BE USED
FOR
$
SECTION A - INDIVIDUAL INFORMATION (Type or
Print)
SECTION B - OTHER PARTY INFORMATION (Type or
Print)
Ind.
Part
Sing Prop.
DBA
LLC
Other
Ind.
Part
Sing Prop.
DBA
LLC
Other
Name
Name
Residence
Address
Residence
Address
City, State &
Zip
City, State &
Zip
Position or
Occupation
Position or
Occupation
Business
Name
Business
Name
Business
Address
Business
Address
City, State &
Zip
City, State &
Zip
Res. Phone
Bus.
Phone
Res. Phone
Bus.
Phone
Name and Address of Nearest Relative (Not Living
With)
Name and Address of Nearest Relative (Not Living
With)
SECTION C - STATEMENT OF FINANCIAL CONDITION AS
OF
ASSETS
LIABILITIES
In
Dollars
In
Dollars
(Omit cents)
(Do not include Assets of doubtful value)
(Omit cents)
Notes payable to banks -
secured
Cash on hand and in
banks
Notes payable to banks -
unsecured
U.S. Gov't. & Marketable Securities-see Schedule
A
Due to
brokers
Non-Marketable Securities - see Schedule
B
Amounts payable to others -
secured
Securities held by broker in margin
accounts
Amounts payable to others -
unsecured
Restricted or control stocks
Accounts and bills
due
Partial interest in Real Estate Equities -
see Schedule
C
Unpaid income
tax
Other unpaid taxes and
interest
Real Estate Owned - see Schedule
D
Real estate mortgages payable
-
Loans
Receivable
Automobiles and other personal
property
see Schedule
D
Other debts -
itemize
Cash value-life insurance - see Schedule
E
Other assets -
itemize
TOTAL
LIABILITIES
NET
WORTH
TOTAL
ASSETS
TOTAL LIAB. AND NET
WORTH
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Alimony, child support, separate maintenance received under:
Court Order
Written Agreement
Oral
Understanding
ANNUAL
INCOME
PERSONAL
INFORMATION
SOURCES OF INCOME FOR YEAR ENDED
__________________________
PLEASE USE SEPARATE SHEET FOR ADDITIONAL
DETAILS
Is any income listed likely to be reduced prior to loan being paid off
No
Yes
(Explain)
Salary
Bonuses &
commissions
Do you have a will?
________
if so, name of
executor.
Dividends
Real estate
income
Are you a partner or officer in any other venture?
If so,
describe.
Other income
Are you obligated to pay alimony, child support or separate maintenance
payments?
If so,
describe.
Are any assets pledged other than described on schedules?
If so,
describe.
TOTAL
Income tax settled through
(date)
Are you a defendant in any suits or legal
actions?
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Do you have any contingent liabilities?
If so,
describe.
Personal bank accounts carried
at:
Savings Account
No:
Checking Account
No:
As endorser, co-maker or guarantor?
On leases or contracts?
Certificates of
Deposit:
Legal
claims
Have you ever been declared bankrupt in the last 10
years?
Other special
debt
No
Amount of contested income tax
liens
Yes (Explain:)
Year?
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PFINSTAT
(2/2/2006)
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