Personal Financial Statement Template - Cornerstone Bank Page 3
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3SCHEDULE A – CASH, CHECKING AND SAVINGS ACCOUNTS, CERTIFICATES OF DEPOSIT, MONEY MARKET FUNDS, ETC.
Name of Financial Institution
Type of Account
Owner
(J)
If Pledged, to Whom?
Balance
SCHEDULE B – U. S. GOVERNMENT & MARKETABLE SECURTIES (Use additional sheet if necessary)
Number of Shares or
Are these Registered,
Exchanges Where
Description
In Name of
Market Value
Face Value of Bonds
Pledged, or Held by Others?
Traded
SCHEDULE C – NON-MARKETABLE SECURITIES (Use additional sheet if necessary)
Are these Registered,
Number of Shares
Description
In Name of
Value
Method of Valuation
Pledged, or Held by Others?
SCHEDULE D – INVESTMENTS IN REAL ESTATE (Use additional sheet if necessary)
%
Mortgage
Description/Location of
Date of Original
Market Value of Your
Present
Monthly
Mortgaged Owed
(J)
Owned
Maturity
Real Estate Investment
Investment/Amount
% of Investment
Balance
Payment
To
By You
Date
SCHEDULE E – LIFE INSURANCE CARRIED, INCLUDING GROUP INSURANCE
Name of Insurance
Beneficiary and
Cash Surrender
Owner of Policy
Face Amount
Policy Loans
Company
Relationship
Value
SCHEDULE F – VESTED INTEREST IN DEFERRED COMPENSATION/PROFIT-SHARING PLANS
%
Manner of Payout
Distribution
Company Name
Account Number
Beneficiary
Amount
Vested
(Annuity, Lump Sum, etc.)
Date
SCHEDULE G – BUSINESS VENTURES (Use additional sheets if necessary)
List Name and Address of Any
Total Assets
Net
Present Net
Your Position/Title
Years in
Your % of
Business Venture In Which You
Line of Business
Listed in Section
Worth of
Value of Your
in Business
Business
Ownership
Are a Principal Partner
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Business
Investment
SCHEDULE H – LOANS OWING BANKS, BROKERS, FINANCE COMPANIES, AND OTHERS (MASTERCARD, VISA, ETC.)
Date of Original
Date of Final
Owing to (Acct. No.)
(J)
Present Balance
Due
Monthly Payment
Secured by
Borrowing/Amount
Pay’t
The information contained in this statement is provided to induce you to extend or to continue the extension of credit to the undersigned or to others upon the guaranty of
the undersigned. The undersigned acknowledges and understands that you are relying on the information provided herein in deciding to grant or continue credit or to
accept a guaranty thereof. Each of the undersigned represents, warrants, and certifies that (1) the information provided herein is true, correct and complete and gives a
correct and complete showing of the financial condition of the undersigned, (2) the undersigned has no liabilities direct, indirect or contingent except as set forth in this
statement, and (3) legal and equitable title to all assets listed herein is in the undersigned’s sole name, except as may be herein otherwise noted. Each of the undersigned
agrees to notify you immediately and in writing of any change in name, address, or employment and of any material adverse change (1) in any of the information
contained in this statement or (2) in the financial condition of any of the undersigned or (3) in the ability of any of the undersigned to perform its (or their) obligations to
you. In the absence of such notice or a new and full written statement, this should be considered as a continuing statement and substantially correct. You are authorized
to make all inquires you deem necessary to verify the accuracy of the information contained herein, and to determine the credit-worthiness of the undersigned and the
undersigned hereby authorizes all persons of whom you make such inquiries to respond thereto in full. Each of the undersigned authorizes you to answer questions about
your credit experience with the undersigned.
Date signed _______________________________________, __________ Signature (individual)__________________________________________________________
Date signed _______________________________________,___________ Signature (other party)_________________________________________________________
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