Personal Financial Statement Template - Cornerstone Bank

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PERSONAL FINANCIAL STATEMENT prepared for CORNERSTONE BANK
Submitted to: ____________________________________________________________
Date: ________________________________________________________
____________________________________________________________
IMPORTANT: Read these directions before completing this Statement
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, or if this statement relates to your guaranty of the indebtedness of other
person(s), firm(s), or corporation(s), complete only Sections 1, 3, and 4.
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. Provide information in Section 2 about the
person whose alimony, support, or maintenance payments or income or assets you are relying on. Alimony, child support, or separate
maintenance income, need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
Section 1 – Individual Information
Section 2 – Other Party Information
Name ________________________________________________________________
Name _____________________________________________________________
Address ______________________________________________________________
Address ___________________________________________________________
City, State & Zip _______________________________________________________
City, State & Zip ____________________________________________________
Social Security # ________________________________________________________
Social Security # _____________________________________________________
Date of Birth ___________________________________________________________
Date of Birth ________________________________________________________
Position or occupation ____________________________________________________
Position or occupation ________________________________________________
Business name __________________________________________________________
Business name ______________________________________________________
Business address ________________________________________________________
Business address _____________________________________________________
City, State & Zip ________________________________________________________
City, State & Zip ____________________________________________________
Length at present address _________________________________________________
Length at present address ______________________________________________
Length of employment ___________________________________________________
Length of employment ________________________________________________
Res. Phone _________________________ Bus. Phone _________________________
Res. Phone _________________________ Bus. Phone ______________________
Have (either of) you or any firm in which you were a major owner ever declared bankruptcy, or settled any debts for less than the amounts owed?
If yes, please provide details on a separate sheet.
Yes
No
Are (either of) you a defendant in any suit or legal action?
Yes
No
Are (either of) you presently subject to any unsatisfied judgments to tax liens?
Yes
No
When, if ever, have (either of) you been audited by IRS?
Date: __________________
Are (either of) your assets held in a Trust?
Yes
No If so, what type?
Living
Revocable
Non-Revocable
Other ____________________
Section 3 – Statement of Financial Condition as of_____________________, ________________
In dollars
Liabilities
In dollars
(omit cents)
If joint,
(omit cents)
If joint,
Assets
[Individual]
[Joint]
with
[Individual]
[Joint]
with
(Do not include assets of doubtful value)
whom
whom
Cash, Checking & Savings, CD’s – see
Notes payable to banks &
Schedule A
others – see Schedule H
U.S. Gov’t & marketable securities – see
Schedule B
Due to brokers
Non-marketable securities – see
Amounts payable to others –
Schedule C
secured
Securities held by broker in margin
Amounts payable to others –
accounts
unsecured
Restricted, control or margin account
stocks
Accounts & bills due
Real estate owned – see Schedule D
Unpaid income tax
Accounts, loans, & notes receivable
Other unpaid taxes & interest
Real estate mortgages payable
Automobiles
– see Schedules D & H
Cash surrender value-life insurance – see
Schedule E
Vested interest in deferred
compensation/profit-sharing plans – see
Schedule F
Business ventures – see Schedule G
Other assets/personal property itemize –
see Schedule G if applicable
Total Liabilities
Net Worth
Total Liabilities & Net
Total Assets
Worth
1

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