Download PDFPersonal Financial Statement "*" indicates required fields Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Business / Occupation* Partner / Officer in any other venture? Yes No Partner / Officer Explanation* Are any assets pledged? Yes No Assets Pledged Explanation* Composition Settlement or Bankruptcy? Yes No Have you ever made a composition settlement or filed for bankruptcy?Composition Settlement or Bankruptcy Explanation*For the purpose of procuring and maintaining credit from time to time in any form whatsoever with above named Surety, for claims and demands against the undersigned, the undersigned submits the following as being a true and accurate statement of its financial condition on the following date, and agree that if any change occurs that materially reduces the means or ability of the undersigned to pay all claims or demands against it, the undersigned will immediately and without delay notify the said Surety, and unless the Surety is so notified it may continue to rely upon the statement herein given as a true and accurate statement of the financial condition of the undersigned as of the close of the previous input business. Income from alimony, child support or maintenance payments need not be revealed if the undersigned does not choose to disclose such income in applying for credit. Banking RelationsName / LocationCash BalanceLoan AmountLoan MaturityHow is loan endorsed, guaranteed, or secured? Add RemoveA list of all bank, savings, and loan accountsAccounts, loans, and other notes receivableName / Address of DebtorAmount OwingAge of DebtDescription of DebtDescription of SecurityDate of Expected Payment Add RemoveA list of the largest amounts owing to meLife InsuranceInsured NameBeneficiary NameInsurance CompanyPolicy TypeFace AmountSurrender ValueTotal LoansAnnual PremiumPolicy Assigned YesNo Add RemoveOther Stocks and BondsFace Value / Number of SharesDescription of SecurityRegistered in Name ofCostPresent Market ValueIncome Received Last YearIf Pledged, to Whom Add RemoveReal EstateDescription of Street NumberDimensions or AcresList of ImprovementsMortgages of LeinsPayment Amt. & Due DateAssessed ValuePresent Market ValueUnpaid Taxes (Year)Unpaid Taxes (Amount) Add RemoveReal Estate - OtherThe legal and equitable title to all the real estate listed in this statement is solely in the name of the signatory, except the above. AssetsCash on hand and in the bank (Schedule 1)Please enter a number greater than or equal to 0.US government securitiesPlease enter a number greater than or equal to 0.Accounts, loans, and receivable (Schedule 2)Please enter a number greater than or equal to 0.Cash surrender life insurance (Schedule 3)Please enter a number greater than or equal to 0.Other stocks and bonds (Schedule 4)Please enter a number greater than or equal to 0.Real Estate (Schedule 5)Please enter a number greater than or equal to 0.Number of AutomobilesPlease enter a number greater than or equal to 0.Total value of AutomobilesPlease enter a number greater than or equal to 0.Other assets (itemized)AssetValue Please enter a value greater than or equal to 0. Add RemoveTotal Asset Value Liabilities & Net WorthNotes payable to banks - Secured (Schedule 1)Please enter a number greater than or equal to 0.Notes payable to banks - Unsecured (Schedule 1)Please enter a number greater than or equal to 0.Notes payable to relativesPlease enter a number greater than or equal to 0.Accounts and notes payable to othersPlease enter a number greater than or equal to 0.Rents and interest duePlease enter a number greater than or equal to 0.Taxes due (Schedule 5)Please enter a number greater than or equal to 0.Leans on real estate (Schedule 5)Please enter a number greater than or equal to 0.Estimated Net WorthPlease enter a number greater than or equal to 0.Other liabilities (itemized)LiabilityValue Please enter a value greater than or equal to 0. Add RemoveTotal LiabilitiesTotal Liabilities with Net Worth IncomeSalaryPlease enter a number greater than or equal to 0.Bonus and commissionsPlease enter a number greater than or equal to 0.Dividends and interestPlease enter a number greater than or equal to 0.Real estate incomePlease enter a number greater than or equal to 0.Total Income Contingent LiabilitiesAs endorser or co-makerPlease enter a number greater than or equal to 0.On loans or contractsPlease enter a number greater than or equal to 0.Legal claimsPlease enter a number greater than or equal to 0.Provisions for Federal Income TaxPlease enter a number greater than or equal to 0.Other special debtPlease enter a number greater than or equal to 0.Total Contingent Liability Insurance CoverageFire Insurance - BuildingsPlease enter a number greater than or equal to 0.Fire Insurance - Household effects and autosPlease enter a number greater than or equal to 0.Liability insurance - AutomobilesPlease enter a number greater than or equal to 0.Liability insurance - PersonalPlease enter a number greater than or equal to 0.Liability insurance - General PublicPlease enter a number greater than or equal to 0.Other InsuranceInsuranceValue Please enter a value greater than or equal to 0. Add Remove Comparison of Monthly Income / ExpensesNet monthly incomePlease enter a number greater than or equal to 0.Rent or home paymentPlease enter a number greater than or equal to 0.Food and utilitiesPlease enter a number greater than or equal to 0.IncidentalsPlease enter a number greater than or equal to 0.Average amount paid on open accountsPlease enter a number greater than or equal to 0.Total ExpensesDifference between income and expenses Conclusion That concludes the questionnaire. Thank you for taking the time to fill out this information. Please go back and review your information prior to submitting. The undersigned certifies that the information inserted on both pages hereof has been carefully read and is true and correct.Electronic Signature*CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
