Personal Financial Statement - Texas Department Of Banking
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4Texas Department of Banking
Personal Financial Statement
As of: _______________________
IF ASSETS ARE JOINTLY OWNED, BOTH PARTIES MUST SIGN THIS STATEMENT.
(Fill in all blanks, writing “NO” or “NONE” where necessary to complete information requested.)
Provide additional sheets as necessary and sign and date each additional sheet provided.
and
)
-
Name(s):
Business Phone:
:
)
-
Residence Address:
Residence Phone
)
-
City, State, & Zip Code:
Cell Phone:
Business Name of Applicant/Borrower:
ASSETS
LIABILITIES
Cash on hands and in Banks
Accounts Payable
$
$
Savings Accounts
Notes & Leases Payable to Banks and Others
(Describe in Section 2)
IRA or Other Retirement Account
Installment Account (Auto)
Mo. Payments $
Accounts & Notes Receivable
Installment Account (other) Mo. Payments
$
Life Insurance-Cash Surrender Value Only
Loan on Life Insurance
(Complete Section 8)
Stocks and Bonds (Describe in Section 3)
Mortgages on Real Estate (Describe in Section 4)
Real Estate - (Describe in Section 4)
Unpaid Taxes - (Describe in Section 6)
Automobile - Present Value
Other Liabilities - (Describe in Section 7)
Other Personal Property - (Describe in Section 5)
$
Total Liabilities
0.00
Other Assets - (Describe in Section 5)
Net Worth
TOTAL
$
TOTAL
$
0.00
0.00
Section 1.
Source of Income
Contingent Liabilities Describe all including amounts.
Salary
$
As Co-Maker, Endorser, Surety, Bondsman,
$
$
$
Net Investment Income
Have any Legal Claims & Judgments
Real Estate Income
$
Provision for Federal Income Tax
$
(Describe in Section 6)
Other Income (Describe Below)*
$
Other Special Debt including
$
Letters of Credit and Leases
Description of Other Income in Section 1.
Alimony or child support payments need not be disclosed in "Other Income" unless it is desired to have such payments counted toward total income
Yes
No
Are any returns being contested?
Are your tax obligations current?
Income tax returns are filed through (date)
Yes
No
(Describe in Section 6)
Have either you or any firm in which you were a major owner ever
Do you have a line of credit or an unused credit facility
If so where?
Yes
No If so, provide details
Yes
No
how much?
declared bankruptcy?
at any other institution?
Section 2.
Notes & Leases Payable to Banks and Others
(Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)
Name and Address of Noteholder(s)
Original
Current
Payment
Frequency
How Secured or Endorsed
Balance
Balance
Amount
(Monthly, etc.)
Type of Collateral
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
CORP-G01 (7/14)
Texas Department of Banking
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