Personal Financial Statement Page 2
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2CONFIDENTIAL
SECTION II (
Continued)
B LIFE INSURANCE
(List only those Policies that you own)
Cash Surrender
Policy Loan from
Other Loans Policy
Value
Insurance Co.
as Collateral
Company
Face of Policy
BENEFICIARY
$0.00
$0.00
TOTALS
C SECURITIES OWNED
Face Value-Bonds
Indicate those Not
Market Value U.S.
Market Value
MARKET VALUE Not Readily Marketable
No. of Shares Stock
Registered in Your
Type of Ownership
COST
Gov. Sec.
Marketable Sec.
SECURITIES
Amount Pledged to Secured Loans
TOTALS
$0.00
$0.00
$0.00
D NOTES AND ACCOUNTS RECEIVABLE
(Money Payable or Owed to You Individually-Indicate by a X if Others have an Ownership Interest)
Balance Due Good
Balance Due
Bal. Due Notes Rel. &
MAKER/DEBTOR
When Due
Original Amount
Accounts
Doubtful Accounts
Friends
Security (if any)
X
TOTALS
$0.00
$0.00
$0.00
E REAL ESTATE OWNED
(Indicate by a X if Others have an Ownership Interest)
MORTGAGE OR CONTRACT PAYABLE
TITLE IN NAME
Description &
Present Value of Real
Amount of Ins.
OF
Location
Date Acquired
Original Cost
Estate
Carried
Bal. Due
Payment
Maturity
To Whom Payable
X
TOTAL
$0.00
TOTAL
$0.00
F MORTGAGES AND CONTRACTS OWNED
(Indicate by a if Others have an Ownership Interest)
Contract
Mortgage
X
Maker Name
Maker Address
Start Date
Payment
Maturity
Balance Due
Property Covered
TOTALS
$0.00
G PERSONAL PROPERTY
(Indicate by a X if Others have an Ownership Interest)
X
Date When New
Cost When New
Value Today
Balance Due
DESCRIPTION
To Whom Payable
TOTAL
$0.00
H NOTES
(Other than Bank, Mortgage and Insurance Company Loans)
Other Obligors (if
Notes Due To Rel. &
Notes Due 'Others'
Accounts & Bills
PAYABLE TO
any)
When Due
Friends
(Not Banks)
Payable
Contracts Payable
COLLATERAL (if any)
TOTALS
$0.00
$0.00
$0.00
$0.00
For the purpose of procuring credit from time to time, I/We furnish the foregoing as a true and accurate statement of my/our financial condition.
Authorization is hereby given to the Lender to verify in any manner it deems appropriate any and all items indicated on this statement. The undersigned also
agrees to notify the Lender immediately in writing of any significant adverse change in such financial condition.
Signature:
Signature:
Date:
PERSONAL FINANCIAL STATEMENT
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