Personal Financial Statement - Capitol National Bank
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1
2Individual (Personal)
Confidential
CAPITOL NATIONAL BANK
LANSING, MICHIGAN
Date of Statement
Name:
Address:
Business:
Social Security Number(s):
The undersigned, for the purpose of procuring and maintaining credit with Capitol National Bank on negotiable paper or otherwise hereby furnish and
warrant the following facts, which fully and truly represent the financial condition of the undersigned on the
day of
(should the day be left blank, the date of the statement will be taken for the day), which facts and representations you can consider as
continuing and remaining full, true and accurate unless notice of change is given you, and agreement is hereby made, to notify you promptly of any change
in financial condition that materially reduces the pecuniary responsibility of the undersigned.
It is hereby expressly agreed and understood that in the event I make application for further credit or for the renewal or extension of any existing
indebtedness, this statement shall be valid and binding as if delivered as a true and correct statement of my financial condition on the date such further
credit, extension or renewal is requested and granted.
FILL ALL BLANKS. WHERE NO ANSWER IS GIVEN, “NO” OR “NONE” WILL BE TAKEN FOR YOUR ANSWER
Applicant
Co-Applicant
Joint
Applicant
Co-Applicant
Joint
Cash on hand and in Banks
$
$
$
$
Notes Payable (Schedule F):
(Schedule A)
Notes Receivable
Banks – Secured
Accounts Receivable
Banks – Unsecured
Marketable Securities (Schedule B)
Others
Life Ins. – Cash Surrender Value
Account Payable
(Schedule D)
Retirement Accounts (Schedule E)
Taxes: Income & Property
Life Insurance – Loans (Schedule D)
TOTAL CURRENT LIABILITIES
Mtg or Land Contract on Residence
TOTAL CURRENT ASSETS
(Schedule C)
Mortgage on Other Real Estate
Residence (Schedule C)
(Schedule C)
Mtg on Real Estate Sold on Contract
Other Real Estate (Schedule C)
(Schedule C)
Real Estate Sold on Land Contract
Land Contracts Payable
(ScheduleC)
Partnership/PC Interests
(Schedule G)
Mortgages Receivable
Furniture, Fixtures, Machinery
Other Liabilities (Itemize)
Automobiles
Other Assets (Itemize)
TOTAL LIABILITIES
TOTAL ASSETS
NET WORTH
TOTAL
Personal -please check yes or no
Annual Income
(if any answer is yes, please explain below)
Yes
No
Applicant
Co-Applicant
Total
Are all bad and doubtful assets excluded from this
Salary
$
$
&
statement?
Are (either of) you a partner in any firm or affiliated
Bonuses & Commissions
with any other business?
Have (either of) you filed bankruptcy?
Interest & Dividends
Do (either of) you have any contingent liabilities (co-
maker or guarantor)?
Real Estate Income
Do (either of) you have a will?
Are (either of) you a defendant in any suit or legal
Investments (Stocks & Bonds)
action?
Have (either of) you been audited by the IRS?
Other Income
Are (either of) you presently subject to any unsatisfied
judgements to tax liens or other judgements?
Explanation of other income:
Are (either of) you delinquent on any mortgage
payments?
Have (either of) you any contingent liabilities?
Explanation for any “Yes” answers on the left:
- For notes receivable discounted - $_____________
- For accommodation or endorsement for others
$ _____________________________________
- For Leases $_______________________________
- For Notes with others $______________________
- For actual or threatened litigations $____________
- As guarantor or bondsman $__________________
- Other than above $__________________________
S
A –C
H
& I
B
CHEDULE
ASH ON
AND
N
ANKS
Name of Financial Institution
Type of Account
Owner(s)
Balance
If Pledged, to Whom?
$
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