PERSONAL FINANCIAL STATEMENT

PERSONAL FINANCIAL STATEMENT
As of:
Name:			Spouse Name: (if married see note 1 below)
Social Security Number:			Social Security Number:
Date of Birth:			Date of Birth:
Residence Street Address:			Residence Street Address:
City, State, Zip:			City, State, Zip:
Residence Phone:			Residence Phone:
Business/Employer:			Business/Employer:
Business Phone:			Business Phone:

ASSETS	(Omit Cents)	LIABILITIES	(Omit Cents)
Cash on hand in Bank/Savings Accounts	$	Accounts Payable	$
IRA or Other Retirement Accounts	$	Notes Payable to Banks and Others (Describe in Section 2)	$
Notes Receivable	$	Installment Account (Auto) Mo. Payments $ _____	$
Life Insurance-Cash Surrender Value Only (Complete in Section 8)	$	Installment Account (other) Mo. Payments $ _____	$
Stocks/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)	$
Personal Property (Describe in Section 5)	$	Other Liabilities (Describe in Section 7)	$
Other Assets (Describe in Section 5)	$	Total Liabilities	$
Total Assets	$	Less Total Assets	$
		Net Worth	$

Section 1. Source of Income		Contingent Liabilities
Salary	$	As Endorser or Co-Maker	$
Net Investment Income	$	Legal Claims & Judgments	$
Real Estate Income	$	Provision for Federal Income Tax	$
Other Income _____________________ (See Note 2 below.)	$	Other Special Debt	$

Section 2. Notes Payable to Bank 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 Balance	Current Balance	Payment Amount	Frequency (monthly, etc.)	How Secured/Endorsed Type of Collateral

Note 1. Spouse information need not be revealed unless you reside in Arizona or other community property state.

Note 2. Alimony, child support or separate maintenance income need not be revealed unless you wish to have them considered as a basis for repaying the requested credit.

Section 3. Stocks and Bonds		(Use attachments if necessary. Each attachment must be identified as a part of this statement and signed)
Number of Shares	Name of Securities		Cost	Market Value Quotation/Exchange	Date of Quotation/Exchange	Total Value

Section 4. Real Estate Owned	(List each parcel separately. Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)
	Property A	Property B	Property C
Type of Property
Address
Date Purchased
Original Cost
Present Market Value
Name of Mortgage Co.
Address of Mortgage Co.
Mortgage Account Number
Mortgage Balance
Payment per Month
Status of Mortgage

Section 5. Other Personal Property and Other Assets (Please describe if any is pledged as security, state name and address of lien holder, amount

of lien, terms of payment, and if delinquent, describe delinquency)

Section 6. Unpaid Taxes. (Please describe in detail as to type, to whom payable, when due, amount, and to what property, if any. a tax lien attaches).

Section 7. Other Liabilities (Please describe in detail).

Section 8. Life Insurance Held. (Please provide face amount and cash surrender value of policies - name of insurance company and beneficiaries).

____	Yes	____	No	1. Are any of the Assets held in trust, in an estate or in any other name or capacity?
____	Yes	____	No	2. Were any of the Assets (i) owned or claimed by your spouse before marriage; or (ii) acquired by your spouse during marriage by gift or inheritances; or (iii) recovered for personal injuries sustained by your spouse during marriage; or (iv) acquired from the proceeds or liquidation of any of the preceding?
____	Yes	____	No	3. Are any of your real estate properties used by you in your business?
____	Yes	____	No	4. Do any of your Assets secure any debts which have not been reported in the preceding schedules?
____	Yes	____	No	5. Are you a party to any suit or are there any unsatisfied judgements against you?
____	Yes	____	No	6. Have you been through bankruptcy or made an assignment for benefit of creditors?
I have explained fully under "Additional Remarks" on this page any "Yes" answers to the foregoing questions.
___	Yes	___	No	7. I have made a will; the executor is ____________________________________________.

Additional Remarks

The above financial and supporting schedules, which are submitted to you for the purpose of obtaining credit from you, present a true, complete and correct statement of my financial condition as of the date shown. I understand that misrepresenting information on this statement is a criminal offense under federal law punishable by a fine and/or imprisonment.

I will notify you in writing of any material unfavorable change in my financial condition. In the absence of such notice, you may consider this a continuing statement and substantially correct. If I apply for further credit, this statement shall have the same force and effect as if delivered as an original statement of my financial condition at the time I request such further credit. You are authorized to contact any appropriate third parties for the purpose of verifying any stated information herein or at any time furnished by me to you, and obtaining credit information at any time from any of my creditors and or credit reporting agencies. This financial statement and any other information furnished to you shall be your property. You are authorized to answer questions about your credit experience with me. It is understood that the information provided herein may be shared with any subsidiary or affiliate.

Signature:

Date:

Signature:

Date: