Personal Financial Statement
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1
2
3PERSONAL FINANCIAL STATEMENT
CONFIDENTIAL
IMPORTANT: DIRECTIONS TO APPLICANT
Read directions before completing Financial Statement.
To: __________________________________
Please check appropriate box
Individual credit—If relying on your own income and assets and not the
Address: _____________________________
income and assets of a spouse or another person as a basis for
___________________________________
extension or repayment or credit, complete the Financial Statement below
___________________________________
only as itapplies to you, individually. Do not provide any information
Personal Financial Statement as of __________________
about a spouse or other person. Sign the Financial Statement.
(DATE)
Joint Credit
If applying for joint credit or for individual credit relying
on income or assets of a spouse or another person
APPLICANT’S NAME(S): ________________
for extension and repayment of credit requested,
___________________________________
Individual relying
complete the Financial Statement below. Include
upon income or
information about income, assets and liabilities of the
HOME ADDRESS ______________________
assets of spouse
spouse or other person. Both Applicant and Spouse
___________________________________
or other person.
or Co-Applicant sign this statement.
___________________________________
Please do not leave any questions unanswered. Use “no” or “none” where
HOME PHONE ________________________
necessary.
In Even
In Even
Assets
Dollars
Liabilities and Net Worth
Dollars
Cash on hand and in Banks—See Schedule A
$
Notes Payable: This Bank—See Schedule A
$
U.S. Government Securities—See Schedule B
Notes Payable: Other Institutions—See
Listed Securities—See Schedule B
Schedule A
Unlisted Securities—See Schedule B
Notes Payable—Relatives
Other Equity Interests—See Schedule B
Notes Payable—Others
Accounts and Notes Receivable
Accounts and Bills Due
Real Estate Owned—See Schedule C
Unpaid Taxes
Mortgages and Land Contracts Receivable—
Real Estate Mortgages Payable—See
See Schedule D
Schedule C or D
Cash Value Life Insurance—See Schedule E
Land Contracts Payable—See Schedule C or D
Other Assets: Itemize
Life Insurance Loans—See Schedule E
Other Liabilities: Itemize
TOTAL LIABILITIES
$
NET WORTH
$
TOTAL ASSETS
$
TOTAL LIABILITIES AND NET WORTH
$
In Even
Sources of Income
Dollars
General Information
Salary
$
Employer
Bonus and Commissions
Position or Profession
No. Years
Dividends
Employer’s Address
Real Estate Income
Phone No.
*Other Income: Itemize
Partner, officer or owner in any other venture?
No
Yes
If so, explain:
$
TOTAL
*Alimony, child support or separate maintenance payments need not
be disclosed unless relied upon as a basis for extension of credit. If
Are any assets pledged?
No
Yes Detail in Schedule A
disclosed, payments received under
court order
written
agreement
oral understanding.
Income taxes settled through (Date)
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