C2. PERSONAL FINANCIAL STATEMENT

PERSONAL FINANCIAL STATEMENT
Statement Date

MonthDayYear
Date
Name
Address
City State Zip
Home Telephone
SSN
Birthdate

MonthDayYear
Date
Number of Dependents
Business Telephone
SECTION 1. ASSETS
1 Cash on Hand & in Banks
2 Cash Value of Life Insurance
3 U.S. Gov. Securities
4 Other Marketable Securities
5 Notes Accounts Receivable Good
6 Other Assets Readily Convertible to Cash - Itemize
7 Other Assets Readily Convertible to Cash - Itemize
8 Other Assets Readily Convertible to Cash - Itemize
9 Other Assets Readily Convertible to Cash - Itemize
10 TOTAL CURRENT ASSETS - Leave blank
11 Real Estate Owned
12 Mortgages Contracts Owned
13 Notes & Accounts Receivable Doubtful
14 Notes Due from Relatives Friends
15 Other Securities Not Readily Marketable
16 Personal Property
17 Other Assets Itemize
18 Other Assets Itemize
19 Other Assets Itemize
20 TOTAL ASSETS - Leave blank
LIABILITIES
21 Notes Due to Banks
22 Notes Due to Relatives & Friends
23 Notes Due to Others
24 Accounts & Bills Payable
25 Unpaid Income Taxes Due - Federal State
26 Other Unpaid Taxes & Interest
27 Loans on Life Insurance Policies
28 Contract Accounts Payable
29 Cash Rent Owed
30 Other Liabilities Due within 1 Year Itemize
31 Other Liabilities Due within 1 Year Itemize
32 Other Liabilities Due within 1 Year Itemize
33 TOTAL CURRENT LIABILITIES - Leave Blank
34 Real Estate Mortgage Payable
35 Liens Assessments Payable
36 Other Debts Itemize
37 Other Debts Itemize
38 TOTAL ASSETS - Leave Blank

39 Net Worth (Total Assets - Total Liabilities) - Leave Blank
40 TOTAL LIABILITIES & NET WORTH - Leave Blank
ANNUAL INCOME
Salary Bonuses Commissions
Dividends Interest
Rental Lease Income Net
Other Income Itemize
Other Persons Salary Bonuses Commissions
Other Income of Other Person Itemize
ESTIMATE OF ANNUAL EXPENSES
Income Taxes
Other Taxes
Insurance Premiums
Mortgage Payments
Rent Payable
Other Expenses
GENERAL INFORMATION
Are any Assets Pledged?

NoYes
Are you a Defendant in any Suits or Legal Actions?

NoYes, Please explain below
Explain
Have you ever been declared Bankrupt in the last 10 years?

NoYes, Please explain below
Explain
CONTINGENT LIABILITIES
As Endorser Comaker or Guarantor Yes
On Leases or Contracts
Legal Claims
Federal State Income Taxes
Other
SECTION II. A - CASH IN BANKS AND NOTES DUE TO BANKS
COLLATERAL (If any) Notes Due Banks& Type of Ownership
TOTALS
PERSONAL FINANCIAL STATEMENT
CONFIDENTIAL
B LIFE INSURANCE (List only those Policies that you own)

Other Loans Policy Policy Loan from as Collateral Insurance Co.
C SECURITIES OWNED
Face Value-BondsIndicate those Not No. of Shares StockRegistered in YourType of Ownership

Market ValueMARKET VALUE Not Readily Marketable Marketable Sec.

Amount Pledged to Secured Loans
D NOTES AND ACCOUNTS RECEIVABLE
(Money Payable or Owed to You Individually-Indicate by a X if Others have an Ownership Interest) Bal. Due Notes Rel. & Balance Due GoodBalance Due Doubtful AccountsFriends Original AmountAccounts

E REAL ESTATE OWNED TITLE IN NAME OF

Description & LocationDate AcquiredOriginal Cost X

(Indicate by a X if Others have an Ownership Interest)

Present Value of RealAmount of Ins. EstateCarried

F MORTGAGES AND CONTRACTS OWNED (Indicate by a if Others have an Ownership Interest)
Maturity
Balance Due
G PERSONAL PROPERTY
(Indicate by a X if Others have an Ownership Interest) Value Today
H NOTES
(Other than Bank, Mortgage and Insurance Company Loans) Other Obligors (if any)

Notes Due 'Others' Notes Due To Rel. & Accounts & Bills Friends (Not Banks)Payable
For the purpose of procuring credit from time to time, I/We furnish the foregoing as a true and accurate statement of my/our financial condition. Authorization is hereby given to the Lender to verify in any manner it deems appropriate any and all items indicated on this statement. The undersigned also agrees to notify the Lender immediately in writing of any significant adverse change in such financial condition.
BORROWER's Signature

Clear
Co-Borrower's Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

PERSONAL FINANCIAL STATEMENT

SECTION 1. ASSETS

10 TOTAL CURRENT ASSETS - Leave blank

20 TOTAL ASSETS - Leave blank

LIABILITIES

33 TOTAL CURRENT LIABILITIES - Leave Blank

38 TOTAL ASSETS - Leave Blank

ANNUAL INCOME

ESTIMATE OF ANNUAL EXPENSES

GENERAL INFORMATION

CONTINGENT LIABILITIES

SECTION II. A - CASH IN BANKS AND NOTES DUE TO BANKS

TOTALS

PERSONAL FINANCIAL STATEMENT

CONFIDENTIAL

C SECURITIES OWNED

D NOTES AND ACCOUNTS RECEIVABLE

G PERSONAL PROPERTY

H NOTES