| PERSONAL FINANCIAL STATEMENT |
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Statement Date: |
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Provide a separate statement for each person owning 20% or more of the business and/or other guarantors. |
| Legal Name(s) |
Social Security Number |
Date of Birth |
| 1. |
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| 2. |
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| Home Street Address (no PO Boxes) |
Home Phone |
| 1. |
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| 2. |
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| Income* |
Personal Information |
| Salary |
1. |
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$ |
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Occupation or Type of Business |
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# Dependents |
| 2. |
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1. |
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| Bonus/Commissions |
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2. |
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| Dividends/Interest |
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Employer |
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# Yrs. |
Position/Title |
| Net Rental/Royalties |
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1. |
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| Other (itemize) |
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2. |
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| Total Annual Income |
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$ |
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* Alimony, child support or separate maintenance need not be reported if you do not wish to have it considered. |
| Other Information |
| Endorser/comaker on loans? |
__Yes __No |
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Any outstanding tax obligations? |
__Yes __No |
Brief Description: |
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| Any assets held in trust? |
__Yes __No |
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Any unsettled suits/judgments? |
__Yes __No |
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| Bankruptcy ever filed? |
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__Yes __No |
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| Assets |
Jointly Held? |
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Liabilities |
| Cash |
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$ |
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Schedule B* |
Lines of Credit |
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$ |
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| Investments-Stocks/Bonds |
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Installment Loans |
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| (attach brokerage statement) |
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monthly payments total $ |
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| Accounts / Loans Receivable |
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Accounts / Notes Payable |
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| IRA / Pension … |
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Credit Cards |
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| Real Estate |
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Real Estate Mortgage |
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| (complete Schedule A below) |
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(complete Schedule A below) |
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| Auto: |
Year |
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Make |
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Income Tax Due |
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| Auto: |
Year |
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Make |
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Other: |
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