Personal Financial Statement Form
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2DEVELOPMENT BANK OF AMERICAN SAMOA
Personal Financial Statement
This statement applies as indicated by the following checked box:
I am applying for separate individual credit in my name only and will be relying on my own income or assets and not the income or
assets of another person to repay the credit requested. Only Sections 1, 3, and the reverse will be completed.
We are voluntarily applying jointly for credit and are providing information on all of our separate and jointly owned assets and income.
If we are the spouses of each other, we will complete all Sections including personal information about both spouses in Sections
1 and 2 and our separate and jointly owned assets and income in Section 3 and the reverse. If we are not the spouses of each
other, each of us will complete Sections 1, 3 and the reverse of separate Personal Financial Statement forms.
This Statement relates to my separate individual guaranty of other person(s) or corporation and I will complete only Sections 1, 3
and the reverse.
This Statement relates to our joint guaranty, which will be signed voluntarily by me and my spouse, guarantying the indebtedness of
other person(s), partnership(s) or corporation(s) and all sections will be completed including personal information about my spouse
in Section 2 and our separate and jointly owned assets and income in Section 3 and the reverse. If this Statement relates to a joint
guaranty, which will be signed voluntarily by me and another person other than my spouse, guarantying the indebtedness of other
person(s), each of us will complete Sections 1, 3 and the reverse of separate Personal Financial Statement forms.
Note: The "Assets" portion of this Statement normally lists only that property that is owned entirely by the person(s) signing the
Statement. If I include assets co-owned with others, I will indicate the name(s) of the co-owner(s) and the type of co-ownership, that is
joint tenancy, tenancy in common or tenancy by the entirety. My spouse will sign only when he/she is also completing this form.
SECTION 1- PERSONAL INFORMATION - Applicant/Guarantor
SECTION 2 - PERSONAL INFORMATION - SPOUSE
Name:
Name:
Address:
Address:
Position or Occupation:
How Long:
Position or Occupation:
Business Name:
Business Name:
Business Address:
Business Address:
Social Security No:
Age:
Social Security No:
Age:
Home No:
Business No:
Business/Cell:
Home No:
Business/Cell:
Fax No:
Email:
Fax No:
Email:
SECTION 3 - STATEMENT OF FINANCIAL CONDITION AS OF: ________________________________________
ASSETS
LIABILITIES
Cash with ANZ:
Loans Payable - Secured & Unsecured:
Cash with BOH:
Cash with Other Banks:
Accounts & Notes Receivable:
Accounts Payable:
Marketable Securities:
Charge Accounts:
Investment in Own Business:
Other:
Life Insurance-Cash Value:
Unpaid Taxes:
Value of Residence:
Residence Mortgages Payable:
Other Real Estate:
Other Real Estate Mortgage Payable:
Installment Accounts:
Automobiles: Make, Model & Year:
Loans on Life Insurance:
Make, Model & Year:
Other Liabilities:
Title in the name of:
Other Personal Property & Furniture:
Other Assets:
TOTAL LIABILITIES:
NET WORTH (Total Assets less Total Liabilities):
TOTAL ASSETS:
TOTAL LIABILITIES NET WORTH:
CONTINGENT LIABILITY: As endorser/guarantor $_______________________
On letters of credit $____________________
Legal claims and judgments (detailed) $__________________________
MONTHLY INCOME
MONTHLY PAYMENTS
Applicants Gross Salary:
Rent or Mortgage:
Overtime (constant & regular recurring):
Note Payments:
Bonus or Commissions:
Charge Accounts:
Dividends & Interest:
Installment Loan:
Rents:
Loans on Life Insurance:
Other (detailed):
Local Income Taxes:
Insurance Premiums:
SUBTOTAL - APPLICANT:
Alimony, Child Support, etc:
SPOUSE'S GROSS SALARY (optional)
Other Fixed Monthly Payments:
OTHER (detailed):
SUBTOTAL - SPOUSE:
TOTAL INCOME:
TOTAL PAYMENTS:
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