This document is a personal financial statement that collects an individual's personal and financial information including name, address, employment details, assets, liabilities, income sources, and expenses. It collects details of the individual's cash, investments, property ownership, insurance policies, debts, income, and contingent obligations. Schedules are included to provide additional details on investments, receivables, property contracts, real estate, and other debts. The individual signs to agree that the information provided is accurate and that any significant changes to their financial condition will be promptly reported.

1. Personal Financial Statement
Name: ___________________________ Social Security Number: _________________ DOB: __________________
Spouse: __________________________ Social Security Number: _________________ DOB: __________________
Home Address: _________________________________________ Years at current Address ___________________
City: _______________________ County: ________________ State: _______ Zip Code: ______________________
Employer: __________________________________________ How long: _______________________________
# Of Dependents: _____________ Marital status: Married ______ Unmarried ______ Separated _______________
Emergency Contact: __________________ Phone Number: ______________ Relationship: ___________________
Assets $ Amount Liabilities $ Amount
Cash in Banks Notes Payable to Banks
Cash on Hand Notes Payable to Others
U.S. Gov. Securities (Schedule 1) Notes Payable to Relatives
Stocks and Bonds (Schedule 1) Accounts & Bills Payable (Schedule 6)
Notes Receivables (Schedule 2) Taxes Payable
Accounts Receivables (Schedule 2) Partnership Related Debt
Real Estate Contracts (Schedule 3) Real Estate Payables (Schedule 3)
Real Estate Owned (Schedule 4) Real Estate Owned (Schedule 4)
Automobiles Owned Auto Loans
Personal Property Credit Card Debt
Cash Value Insurance (Schedule 5) Loans on Life Insurance (Schedule 5)
Other Assets Other Debt
Total Liabilities $
Net Worth (Assets Minus Liabilities)
Total Assets $ Total Liabilities & Net Worth
Source of Income $ Amount Cash Expense $ Amount
Gross Wages or Salary Real Estate / Mortgage Payments
Commissions, Bonuses, ETC. Regularly Scheduled Payments
Partnership Draws Income Taxes
Partnership Distributions Partnership Contributions
Interest & Dividends Other Taxes (Real Estate, etc.)
Rental Income Living Expenses & Misc.
Other Income Rental expenses
Other Anticipated Payments
Other
Total Cash Expense
Total Cash Income Net Cash Flow
Contingent Obligations
As Guarantor or Endorser Letters of Credit
On Leases or Contracts Future Capital Contributions
For Legal Claims or Judgments Other
Income Tax Claim or Dispute Total

2. Schedule 1: Stocks and Bonds
Number of Shares Description Value Per Share Total Market Value
Schedule 2: Accounts and Notes Receivable
Due From Monthly
Income
Original
Balance
Present Balance Collateral Comments
Schedule 3: Contracts or Mortgages Owned
Location Monthly
Income
Original
Balance
Present
Balance
Amount
Owed
Monthly
Payment
Owed To
Schedule 4: Real Estate Owned
Address or legal
description
Cost Market Value Mortgage Monthly
Payment
Monthly
Income
Mortgage
Holder
Schedule 5: Life Insurance Policies
Name of Insured Life Insurance
Company
Amount of
Policy
Cash Value Loans Against
Policy
Beneficiary
Schedule 6: Other Debts
Payable To Collateral Payments Balance
Have you ever filed Bankruptcy: Yes ___ No ___ Are you a defendant in any suits or legal action? Yes ___ No ___
Do you have a trust account: Yes ___ No ___ Do you have a will: Yes ___ No ___
For the purpose of procuring and maintaining credit, the undersigned submits the forgoing and following statement and information contained
on both sheets, both written and printed, as being a full, true and correct statement of my financial condition on the date stated. The
undersigned agrees to notify lessor/grantor immediately in writing of any materially unfavorable change in his/her financial condition, and in
the absence of such notice, or a new and full written statement, this may be considered as a continuing statement and substantially correct.
Applicant’s Signature X ___________________________________________________________ Date: _________________________________