Individual - Provide your
financial information only
Joint, with
Information on separate financial
statement
Applicant's
Individual Information
Last Name:
First Name:
Middle Name:
Address:
City:
State:
Zip
code:
Phone No.
E-mail Address:
Date of Birth:
Social Security No.--
Business or Occupation
Employer's Name, Address and Phone
Name:
Address:
City:
State:
Zip
code:
Phone No.
Length of Employment:
Joint Party
Information
Last Name:
First Name:
Middle Name:
Phone No.
E-mail Address:
Date of Birth:
Social Security No.--
Business or Occupation
Employer's Name, Address and Phone
Name:
Address:
City:
State:
Zip
code:
Phone No.
Length of Employment:
Note: Complete Schedules First Prior to Assets
and Liabilities
Assets
Cash on Hand and in Banks: (Schedule
A)
Cash Value of Life Insurance: (Schedule
B)
U.S. Government Securities: (Schedule
C)
Other Marketable Securities: (Schedule
C)
Total Liquid
Assets
Real Estate Owned (Schedule E)
Mortgages and Contracts Owned (Schedule
F)
Personal Property (Schedule G)
Automobiles and Vehicles (Schedule G)
Other Securities - Not Readily Marketable
(Schedule C)
Notes and Accounts Receivable - Current
(Schedule D)
Notes and Accounts Receivable - Past 90 Days
Due (Schedule D)
Notes and Accounts Due from Relatives and
Friends (Schedule D)
IRA and Tax Deferred Accounts
Other Assets (Itemize Schedule X)
Total
Non-Liquid Assets
Total
Assets
Liabilities
Notes Due to Banks (Schedule A)
Notes Due to Relatives and Friends (Schedule
H)
Notes Due to Others (Schedule H)
Accounts and Bills Payable (Schedule
H)
Contract Accounts Payable (Schedule
H)
Loans on Life Insurance Policies (Schedule
B)
Cash Rent Payable
Other Liabilities Due Within 1 Year (Schedule
X)
Total Short
Term Liabilities
Real Estate Mortgages Payable
Liens and Assessments Payable
Other Long Term Debts (Schedule X)
Total Long Term Liabilities
Total
Liabilities
Net Worth
(Total Assets Minus Total Liabilities)
Total Liabilities
and Net Worth
Annual
Income
Salary Bonuses and Commissions
Dividends and Interest
Rental and Lease 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. Other Income (Attach
Separate Sheet for Itemization)
Provide the
following information only if Joint Credit is checked
above.
Joint Party / Person's Salary Bonuses and
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. Joint Party / Other
Person's Other Income (Attach Separate Sheet for
Itemization)
Total
Estimate of
Annual Expenses
Income taxes
Other Taxes
Insurance Premiums
Mortgage Payments
Rent Payable
Other Expenses
Total
General
Information
Are any Assets Pledged Other than Described on
Schedules?
Yes No
Are You a Defendant in Any Suits or Legal
Actions?
Yes No
You have currently filed your income taxes
through what date?
Have you ever been declared Bankrupt in the
last 10 years?
Yes No
Are you a Partner or Officer in any other
Venture?
Yes No
Contingent
Liabilities
Are You an Endorser, Co-maker or
Guarantor?
Yes No
Are You on any Leases or Contracts?
Yes No
Are You involved with any Legal
Claims?
Yes No
Are You subject to any Federal or State Income
Tax Withholding?
Yes No
Others not mentioned above?
Schedules
To be
completed first before above consolidated
Schedule
A
Cash in Banks and Notes Due to
Banks
(List all Real Estate Loans in Schedule
E)
Name of Institution
Type of Account
Type of Ownership
Total on Deposit
Notes Due to Banks
Collateral for Notes (if any)
Payment
Total Cash on Hand
Total Notes Due Banks
See Additional Attached Sheets
Schedule
B
Life Insurance
(list only the Policies that you
own)
Company
Face of Policy
Cash Surrender Value
Policy Loan from Insurance Company
Other Loans, Policy as Collateral
Beneficiary
Totals
Totals
See Additional Attached Sheets
Schedule
C
Securities Owned
(Including U.S. Government Bonds and all other
Stocks and Bonds)
Face Value-Bonds, No. of Shares Stock
Description, Indicate those not in Your
Name
Type of Ownership
Cost
Market Value U.S. Government
Securities
Market Value Marketable Securities
Market Value Not Readily Marketable
Amount Pledged to Secured Loan
Totals
See Additional Attached Sheets
Schedule
D
Notes and Accounts
Receivable
(Money Payable or Owed to You Individually,
Indicate Percent (%) of Your Ownership Interest)
