Personal Financial Statement Form

SECTION 1 – INDIVIDUAL INFORMATION
Full Name *

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position or Occupation
Business Name
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Business Phone Number

Area CodePhone Number

SECTION 2 – OTHER PARTY INFORMATION
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position or Occupation
Business Name
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Business Phone Number

Area CodePhone Number

SECTION 3 – STATEMENT OF FINANCIAL CONDITION
Statement Of Financial Condition As Of

MonthDayYear
Date

Assets (Do not include Assets of doubtful value)

	In Dollars (Omit Cents)
Cash on Hand and in Bank
U.S. Gov’t. & Marketable Securities – see Schedule A
Non-Marketable Securities – see Schedule B
Securities Held by Broker in Margin Accounts
Restricted or Control Stocks
Partial Interest in Real Estate Equities – see Schedule C
Real Estate Owned – see Schedule D
Loans Receivable
Automobiles and Other Personal Property
Cash Value – Life Insurance – see Schedule E
Other Assets – Itemize:

Total Assets

Liabilities

	In Dollars (Omit Cents)
Notes Payable to Banks – Secured
Notes Payable to Banks – Unsecured
Due to Brokers
Amounts Payable to Others – Secured
Amounts Payable to Others – Unsecured
Accounts and Bills Due
Unpaid Income Tax
Other Unpaid Taxes and Interest
Real Estate Mortgages Payable – see Schedule D
Other Debts – Itemize:

Total Liabilities
Net Worth
Total Liabilities And Net Worth
SOURCES OF INCOME FOR YEAR ENDED

MonthDayYear
Date

	Fill In	In Dollars (Omit Cents)
Salary, Bonuses, & Commissions
Dividends
Real Estate Income

Other Income (Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation)

	Fill In	In Dollars (Omit Cents)
1
2
3

Total
CONTINGENT LIABILITIES
Do you have any contingent liabilities? If so, describe:

YesNo

	Fill In	In Dollars (Omit Cents)
As Endorser, Co-Maker, or Guarantor?
On Leases or Contracts?
Legal Claims
Other Special Debt
Amount of Contested Income Tax Liens

Total
PERSONAL INFORMATION
Do you have a will? If yes, name of executor:

YesNo
Name of executor
Are you a partner or officer in any other venture? If so, describe:

YesNo
Are you obligated to pay alimony, child support or separate maintenance payments? If so, describe:

YesNo
Are any assets pledged other than as described on schedules? If so, describe:

YesNo
Income tax settled through (date):

MonthDayYear
Date
Are you a defendant in any suits or legal actions?

YesNo
Personal bank accounts carried at:
Have you ever been declared bankrupt? If so, describe:

YesNo

COMPLETE SCHEDULES, USE ADDITIONAL SCHEDULES IF NECESSARY

Schedule A – U.S. Governments & Marketable Securities

	Number of Shares or Face Value (Bonds)	Description	In Name of	Are These Pledged?	Market Value
1
2
3
4

Schedule B – Non-marketable Securities

	Number of Shares	Description	Are These Pledged?	Source of Value	Value
1
2
3
4

Schedule C – Partial Interests In Real Estate Equities

	Address & Type of Property	Title in Name of	% of Ownership	Date Acquired	Cost	Market Value	Mortgage Maturity	Mortgage Amount
1
2
3
4

Schedule D – Real Estate Owned

	Address & Type of Property	Title in Name of	Date Acquired	Cost	Market Value	Mortgage Maturity	Mortgage Amount
1
2
3
4

Schedule E – Life Insurance Carried, Including N.s.l.i. And Group Insurance

	Name of Insurance Company	Owner of Policy	Beneficiary	Face Amount	Policy Loans	Cash Surrender Value
1
2
3
4

Schedule F – Banks Or Finance Companies Where Credit Had Been Obtained

	Name & Address of Lender	Credit in the Name of	Secured or Unsecured?	Original Date	High Credit	Current Balance
1
2
3
4

The information contained in this statement is provided for the purpose of obtaining, or maintaining credit with you on behalf of the undersigned, or persons, firms or corporations in whose behalf the undersigned may either severally or jointly with others, execute a guaranty in your favor. Each undersigned understands that Mortgage Consultant Group are relying on the information provided herein (including the designation made as to ownership of property) in deciding to grant or continue credit. Each undersigned represents and warrants that the information provided is true and complete and that Mortgage Consultant Group may consider this statement as continuing to be true and correct until a written notice of a change is given to Mortgage Consultant Group by the undersigned. You authorize Mortgage Consultant Group to make all inquiries that we deem necessary to verify the accuracy of the statements made herein, and to determine your credit-worthiness.
Signature (Individual)

Clear
S.S. No.
Date of Birth

MonthDayYear
Date
Signature (Other Party)

Clear
S.S. No.
Date of Birth

MonthDayYear
Date
Date Signed

DayMonthYear
Date

Should be Empty:

CONTINGENT LIABILITIES

PERSONAL INFORMATION