Personal Financial StatementFields marked with * are mandatory

Complete this form for: (1) each proprietor, or (2) each limited partner who owns 20% or more interest and each general partner, or (3) each stockholder owning 20% or more of voting stock and each corporate officer and director, or (4) any other person or entity providing a guaranty on the loan.
Business name of applicant/borrower
Home Address
Home Phone
Business Phone
Assets Omit Cents($) Liabilities Omit Cents($)
Cash on hand and in banks
Accounts payable
Savings accounts
Notes payable to banks and others (Describe in Section 2)
IRA or other retirement accounts
Installment account (Auto) Monthly payments
Accounts and notes receivable
Installment account (Other) Monthly payments $
Life insurance-cash surrender value only (Complete Section 8)
Loan on life insurance
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
Total liabilities
Other personal property (Describe in Section 5)
Net worth
Other assets (Describe in Section 5)
Total $ Total $
Section 1 Source of Income($)   Contingent Liabilities($)
As endorser or co-maker
Net investment income
Legal claims & judgments
Real estate income
Provision for federal income tax
Other income (Describe below)*
Other special debt
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.
Section 2. Notes 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 noteholders Original
How secured or endorsed
Type of collateral
Section 3. Stock 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($) Market value
Date of
Total Value($)
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
Property address
Date Purchased
Original cost($)
Present market Value
Mortgage holder
Address of mortgage holder
Mortgage account number
Mortgage balance($)
Amount of payment per month/year ($)
Status of mortgage
Other personal property and other assets (Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms of payment, and if delinquent, describe delinquency.)
Unpaid Taxes (Describe in detail, as to type. To whom payable, when due amount and to what property, if any, a tax lien attaches.)
Other Liabilities (Describe in detail.)
Life Insurance Held (Give face amount and cash surrender value of policies - Name of insurance company and beneficiaries.)
Lender is authorized to make all inquiries deemed necessary to verify the accuracy of the statements made herein and to determine my/ our creditworthiness. (I) or (We) certify the above and the statements contained in the schedules herein are a true and accurate statement of (my) or (our) financial condition as of the date stated herein.
Social Security Number
Social Security Number