Personal Financial Statement (Page 5 of 5) in pdf

Personal Financial Statement Page 5

___________________________________________________________________

Yes

Have you filed Bankruptcy?

If yes, which chapter?

Filing Date:

__________/_____________/___________

Discharge Date: ________/_____________/___________

If not, why?______________________________________

Have you:

Comprised a debt?

Had a suit or judgment entered against you?

Had a vehicle repossessed?

If this is a statement of you and your spouse, are any assets your

spouse’s separate property?

What assets are held in Joint tenancy?

Are any of your assets held in trust?

CREDIT REFERENCE

NEAREST RELATIVE NOT LIVING WITH

YOU

Name:

Address:

Phone:

Name:

Address:

Phone:

The information on the pages of this form is submitted for the purpose of inducing Lender to extend credit and is a

true, full and correct statement of my/our financial condition as of the date shown. I/we acknowledge and agree

that the Lender will rely upon the information provided on this form and that intentionally false, incomplete or

incorrect information may constitute fraud. While indebted to you, I/we agree to notify you immediately of any

material change of my/our financial condition. In the event that such notification is not given, or if other acts occur

that, in your opinion, either do or could adversely affect the Lender’s interest, then any and all outstanding

obligations may, at your election, become due and payable without demand or notice and may be charged against

any and all assets of the undersigned in possession or control of the Lender.

I authorize the Lender to check my credit references. I also authorize the Lender to provide credit information

arising from this transaction to others as may be reasonably requested.

Applicant’s Signature

Co-Applicant’s Signature

Date

(Where Applicable)

Page 5 of 5

Personal Financial Statement Page 5