Personal Financial Statement
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PERSONAL FINANCIAL STATEMENT
Name
Address
Telephone
Business or Occupation:
Partner or Officer in any other venture?
Are any assets pledged?
Have you ever made a composition settlement or taken bankruptcy? Explain:
For the purpose of procuring and maintaining credit from time to time in any form whatsoever with above named Bank, 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 Bank, and unless the Bank 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 business
____________________________________, 19____. 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.
ASSETS
LIABILITIES AND NET WORTH
Cash on Hand and in Banks (Schedule 1)
$
Notes Payable to Banks – Secured (Schedule 1)
$
U.S. Government Securities
$
Unsecured (Schedule 1)
$
Accounts, Loans and Notes Receivable (Schedule 2)
$
Notes Payable to Relatives
$
Cash Surrender Value Life Insurance (Schedule 3)
$
Accounts and Notes Payable to Others
$
Other Stocks and Bonds (Schedule 4)
$
Rents and Interest Due
$
Real Estate (Schedule 5)
$
Taxes Due (Schedule 5)
$
Automobiles – Number (
)
$
Liens on Real Estate (Schedule 5)
$
Other Assets (Itemize)
$
Other Liabilities (Itemize)
$
$
$
$
$
$
$
$
$
TOTAL LIABILITIES
$
NET WORTH
$
TOTAL ASSETS
$
TOTAL LIABILITIES AND NET WORTH
$
INCOME
CONTINGENT LIABILITIES
Salary
$
As Endorser or Co-Maker
$
Bonus and Commissions
$
On Loans or Contracts
$
Dividends and Interest
$
Legal Claims
$
Real Estate Income
$
Provisions for Federal Income Tax
$
Other Special Debt
$
TOTAL INCOME
$
INSURANCE COVERAGE
COMPARISON OF MONTHLY INCOME AND EXPENSES
Fire Insurance – Buildings
$
Net Monthly Income
$
Household Effects and Autos
$
Rent or Home Payment
$
Liability Insurance - Automobiles
$
Food and Utilities
$
Personal
$
Incidentals
$
General Public
$
Avg. Amt. Paid on Open Accts.
$
Other Insurance
$
TOTAL EXPENSES
$
DIFFERENCE BETWEEN INCOME AN D EXPENSES $
The Federal Reserve Bank does not warrant that this form meets current or future Federal Regulation. You are urged to consult with your bank’s attorneys on
future use of this form in its present format or your own revision.
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