Personal Financial Statement
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1
2PERSONAL FINANCIAL STATEMENT
Cumberland Bank & Trust
2034 Wilma Rudolph Blvd
P.O. Box 30008
Clarksville, TN
37040
IMPORTANT: Read these directions before completing this Financial Statement, and check ( ) the appropriate box below.
* 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 joint credit, but
relying on income from alimony, child
support, or separate maintenanceor 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.
SECTION A
SECTION B
Name:
Name:
Address:
Address:
City, State & Zip:
City, State & Zip:
Occupation:
Occupation:
Business Name:
Business Name:
Business Address:
Business Address:
City, State & Zip:
City, State & Zip:
Res. Phone:
Res. Phone:
Business Phone:
Business Phone:
SECTION C - STATEMENT OF FINANCIAL CONDITION AS OF :
ASSETS
LIABILITIES
In Dollars
In Dollars
(Do not include Assets of doubtful value)
(Omit Cents)
(Omit Cents)
Cash on hand and in banks
Notes Payable to banks - secured
US Gov't & Marketable Securities-see Schd. A
Notes Payable to banks - unsecured
Non-Marketable Securities - see Sched. B
Due to Brokers
Securities held by broker in margin Accounts
Amounts payable to others - secured
Restricted or Control stocks - see Sched. F
Amounts payable to others - unsecured
Partial interest in Real Estate Equities -
Partial Interest in R/E Equities - see Sched. C
Accounts & Bills Due
(see Sched. C)
Real Estate Owned - see Sched. D
Unpaid Income Tax
Loans Recievable
Other unpaid taxes and interest
Automobiles & Personal Property
Real Estate mortgages payable - see Sched. D
Cash Value - Life insurance - see Sched. E
Other debts - Itemized:
Other Assets - Itemize:
TOTAL LIABILITIES :
NET WORTH :
TOTAL ASSETS:
TOTAL LIABILITIES & NET WORTH:
Alimony, child support, or separate maintenance income need not be revealed I
f you do not wish to have it considered as a basis for repaying this obligati
on
Alimony, child support, separate maintenance received under:
Oral Understanding
Written Agreement
Court Or
der
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?
Salary
$
Yes, Explain
No
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
Total :
$
payments? If so describe.
CONTINGENT LIABILITIES
Do you have any Contingent Liabilities?
If so, describe:
Are any assets pledged other than described on schedules? If so, describe.
Income Tax Settled through (date):
Are you a defendant in any suits or legal actions?
As Endo
rser, co-maker or guarantor?
$
Have you ever been declared bankrupt in the last 10 years?
On lease
s or contracts?
$
No
Legal Cl
aims
$
Yes (Explain:) Year?
Other sp
ecial debt
$
Amount
of contested income tax liens
$
Personal Bank Accounts Carried At:
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