Personal Financial Statement - Capitol National Bank Page 2
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1
2S
B – A
S
CHEDULE
LL
ECURITIES
Name of Issuing Corporation
No. of Shares (If Stock)
Portion
Registered in Name of
Market Value
and Type of Security
Face Value (If Bonds)
Pledged
Listed
$
Unlisted
S
C – P
R
& R
E
I
, M
D
(
)
CHEDULE
ERSONAL
ESIDENCE
EAL
STATE
NVESTMENTS
ORTGAGE
EBT
MAJORITY OWNERSHIP ONLY
PERSONAL RESIDENCE
Purchase
Market
Present Loan
Interest
Fixed or
Loan Mat.
Monthly
Legal Owner
Lender
Property Address
Value
Balance
Rate
Adj.
Date
Payment
Year
Price
$
$
$
%
$
INVESTMENT
Purchase
Market
Present Loan
Interest
Fixed or
Loan Mat.
Monthly
Legal Owner
Lender
Property Address
Value
Balance
Rate
Adj.
Date
Payment
Year
Price
$
$
$
%
$
S
D – L
I
CHEDULE
IFE
NSURANCE
Beneficiary and
Cash Surrender
Name of Insurance Company
Owner of Policy
Face Amount
Policy Loans
Relationship
Value
$
$
$
S
E – R
A
: 401
, IRA’
, P
CHEDULE
ETIREMENT
CCOUNTS
K
S
ENSION
Manner of Payout
Company Name
% Vested
Account Number
Distribution Date
Beneficiary
Amount
(Annuity, Lump Sum, etc.)
%
$
S
F – L
B
, O
& C
C
CHEDULE
OANS TO
ANKS
THERS
REDIT
ARDS
Monthly
Account
Maturity
Original
Current
Owing to:
Loan Date
Credit Limit
Collateral
Payment
Number
Date
Balance
Balance
$
$
$
S
G – P
(L
M
O
R
E
P
)*
CHEDULE
ARTNERSHIPS
ESS THAN
AJORITY
WNERSHIP FOR
EAL
STATE
ARTNERSHIPS
Limited or
Date of
Balance Due on
Percent
Current Market
Final Distribution
Type of Investment
General
Initial
Cost
Partnerships:
Owned
Value
Date
Partner
Investment
Notes, Cash Call
$
$
$
*NOTE: For investments which represent a material portion of your total assets, please include the relevant financial statements or tax returns, or in the case of partnership
investments or S-corporations, Schedule k-1s.
I/We, the undersigned, hereby certify and declare that the above statement and representations constitute a true and complete
account of my/our financial condition as of
.
(Date)
This Financial statement and any accompanying tax returns or additional information is being submitted in conjunction with the
loan request of
in the amount of
$
. The credit requested is for
Joint
Individual consideration.
JOINT APPLICATANT ACKNOWLEDGEMENT
Applicant’s Initials
Co-Applicant’s Initials
In addition, I/We authorize Capitol National Bank (the “Bank”) to obtain a consumer credit report about me/us, to obtain any and
all information necessary in connection with the personal/business loan application, and to disclose any of this information to the Bank’s
affiliates for the purpose of evaluating the loan application.
Date Signed
(Signature)
Witness
(Signature of Joint Applicant)
Revision Date 02/12/2009
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