Individual - if you check this box, provide Financial Information only about yourself.
if you check this box, provide Financial information about yourself
Joint, with
Relationship
Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Social Security #
and the other person. Joint Applicant's Name
Our initials here indicate intent to apply for joint credit.
Applicant
Co-Applicant
PERSONAL FINANCIAL STATEMENT OF
Note: Any willful misreptesentation could result in a violation of Federal Law (Sec. 18 U. S. C. 1014)
Name
Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Statement Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
20
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security #
Home Phone
Format: (000) 000-0000.
No. of Dependents
Bus. or Occupation
Bus. Phone
Format: (000) 000-0000.
NOTE: COMPLETE ALL OF SECTION II BEFORE SECTION I
SECTION 1
SECTION 1
Rows
Individual in dollars (omit cents)
Joint in dollars (omit cents)
If Joint, With whom
1. Cash On hand & in Banks Sec. II-A
2. Cash Value of Life Insurance Sec. II-B
3. U.S. Gov Securities Sec. II-C
4. Other Marketable Securities Sec. II-C
5. Notes & Accounts Receivable Good Sec. II-D
6. Other Assets Readily Convertible to Cash Itemize
7.
8.
9.
10. TOTAL CURRENT ASSETS
11. Real Estate Owned Sec. II-E
12. Retirement Assets (401K, IRA, etc.) Sec. II-F
13. Notes & Accounts Receivable Doubtful Sec. II-D
14. Notes Due From Relatives & Friends Sec. II-D
15. Other Securities Not Readily Marketable Sec. II-C
16. Personal Property Sec. II-G
17. Other Assets Itemize
18.
19.
20. TOTAL ASSETS
Rows
Individual in dollars (omit cents)
Joint in dollars (omit cents)
If Joint, With whom
21. Notes due to Banks Sec. II-A
22. Notes Due to Relatives & Friends Sec. II-H
23. Notes due to Others Sec. II-H
24. Accounts & Bills Payable Sec. II-H
25. Unpaid Income Taxes Due Federal State
26. Other Unpaid Taxes & Interest
27. Loans on Life Insurance Policies Sec. II-B
28. Contract Accounts Payable Sec. II-H
29. Cash Rent Owed
30. Other Liabilities Due within 1 Year Itemize
31.
32.
33. TOTAL CURRENT LIABILITIES
34. Real Estate Mortgages Payable Sec. II-E
35. Liens & Assessments Payable
36. Other Debts Itemize
37.
38. Total Liabilities
39. Net Worth (Total Assets minus Total Liabilities)
40. TOTAL LIABILITIES & NET WORTH
Federal
State
ANNUAL INCOME
ESTIMATE OF ANNUAL EXPENSES
Salary, Bonuses & Commissions
Income Taxes
Dividends & Interest
Other Taxes
Rental & Lease Income (Net) excluding interest paid
Insurance Premiums
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.
Mortgage Payments.
Other income - Itemize
Rent Payable
Provide the following information only if Joint Credit is checked above.
Other Expenses
Other Persons Salary, Bonuses & Commissions
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.
TOTAL
Other income of Other Person-Itemize
GENERAL INFORMATION
Are any Assets Pledged?
Yes
No
(See Section II)
As Endorser, Co-Maker or Guarantor
Are you a Defendant in any Suits or Legal Actions?
Yes
No
On Leases or Contracts
(Explain):
Legal Claims
Have you ever declared Bankruptcy?
Yes
No
Federal-State Income Taxes
(Explain):
Other
SECTION 2
A. CASH IN BANKS AND NOTES DUE TO BANKS
SECTION 2 A. CASH IN BANKS AND NOTES DUE TO BANKS
Rows
NAME OF BANK
Type of Account
Type of Ownership
On Deposit
Notes DueBanks
COLLATERAL (If Any & Type of Ownership)
1
2
3
4
5
6
7
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SECTION 3 - CONTINUED
B. LIFE INSURANCE (List only those Policies that you own)
Rows
COMPANY
Face of Policy
Cash Surrender Value
Policy Loan from Insurance Co.
Other Loans Policy as Collateral
BENEFICIARY
1
2
3
4
5
6
C. SECURITIES OWNED (Including U.S. Gov't Bonds and all other Stocks and Bonds)
Rows
Face Value-Bonds No. of Shares Stock
DESCRIPTION Indicate those Not Registered in Your Name
Type of Ownership
COST
Market Value U.S. Gov. Sec.
Market Value Marketable Sec.
Market Value Not Readily Marketable Securities
Amount Pledged to Secure Loans
1
2
3
4
5
6
7
8
D. NOTES AND ACCOUNTS RECEIVABLE (Money Payable or Owed to You Individually - Indicate by a if Others have an Ownership Interest)
Rows
MAKER/DEBTOR
When Due
Original Am't
Balance Due Good Accounts
Balance Due Doubtful Acc'ts
Balance Due Notes Relatives & Friends
SECURITY (If Any)
1
2
3
4
E. REAL ESTATE OWNED (Indicate by a if Others have an Ownership Interest)
Rows
Balance Due
Payment
Maturity
To Whom Payable
$
TOTAL
F. RETIREMENT FUNDS / ASSETS
Rows
OWNER OF ACCOUNT
Type (401K, IRA, etc.)
Brokerage / Bank
Balance
Vested?
Type of Securities Invested
1
2
3
4
G. PERSONAL PROPERTY (Indicate by a if Others have an Ownership Interest)
Rows
Balance Due
To Whom Payable
$
H. NOTES (Other than Bank, Mortgage and Insurance Company Loans), ACCOUNTS AND BILLS AND CONTRACTS PAYABLE
Rows
PAYABLE TO
Other Obligors (If Any)
When Due
Notes Due to Rel. & Friends
Notes Due "Others" (Not Banks)
Accounts & Bills Payable
Contracts Payable
COLLATERAL (If Any)
1
2
3
4
5
I understand that LEY Capital is relying on the information in these documents in connection with credit underwriting and/or verification of financial information necessary for deciding certain financial accommodations or the extension of credit to the undersigned. These documents are delivered to LEY Capital to induce it to extend credit fromtime to time and/or to continue its present extensions of credit and/or to evaluate any decisions involving LEY Capital, at its discretion, for the benefit of the undersigned. The undersigned herby certifies that these documents are correct and complete, and a ccurately reflect the condition and affairs of the undersigned at the date(s) and for the period(s) stated and that said documents reflect all known liabilities direct or contingent, as of the dates(s) thereof.
LEY Capital is authorized to make all inquiries deemed necessary to verify the accuracy of the information contained herein, and to determine the creditworthiness of the undersigned. In addition, the undersigned authorizes LEY Capital to answer questions about its credit experience with the undersigned. The undersigned also represents and warrants that to the undersigned's knowledge there has been no material adverse change in the condition or affairs of undersigned from the date of the financial nent to the date hereof. The undersigned also agrees to notify the Lender immediately in writing of any significant adverse change in such financial condition.
Date Signed
Signature
(Other Person if Applicable)
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