Personal Financial Statement Template (Page 4 of 4) in pdf

Please Answer The

Following Questions:

1. Income tax returns filed through (date): _________________ Are any returns currently being audited or contested?

Yes

If yes, what year(s)?

2. Have (either of) you or any firm in which you were a major owner ever

declared

bankruptcy?

Yes

If yes, please provide details:

3. Have you drawn a will?

Yes

If yes, please furnish the name of the executor(s) and year will

was

drawn:

4. Number of dependents (excluding self) and

relationship

applicant:

5. Have you ever had a financial plan prepared for you?

Yes

6. Did you include two years federal and state tax returns?

Yes

7. Do (either of) you have a line of credit or unused credit facility at any other institution(s)?

Yes

If so, please indicate where, how much, and name of banker:

8. Do you anticipate any substantial inheritances?

Yes

If yes, please explains:

Representations and Warranties

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

guarantee of the undersigned. The undersigned acknowledge and understand that you are relying on the information provided herein in deciding to grant or continue

credit or to accept a guarantee thereof. Each of the undersigned represents warrants and certifies that the information provided herein is true, correct and complete. 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. If the

undersigned fail to notify you as required above, or if any of the information herein should prove to be inaccurate or incomplete in any material respect, you may declare

the indebtedness of the undersigned or the indebtedness guaranteed by the undersigned, as the case may be, immediately due and payable. You are authorized to make all

inquiries you deem necessary to verify the accuracy of the information contained herein and to determine the credit-worthiness of the undersigned. The undersigned

authorize any person or consumer reporting agency to give you any information it may have on the undersigned. Each of the undersigned authorizes you to answer

questions about your credit experience with the undersigned. As long as any obligation or guarantee of the undersigned to you is outstanding, the undersigned shall

supply annually an updated financial statement. This personal financial statement and any other financial or other information that the undersigned give you shall be

your property.

Date

Your Signature

Date

Co-Applicant's Signature (if you are requesting

The financial accommodation jointly)