Pesonal Financial Statement
GENERAL INFORMATION PERSONAL INFORMATION
Are any assets pledged?
If yes, please list in schedule below.
Business or Employer – Applicant:
Are you a defendant in any suits or legal actions? Co-applicant:
US Citizen? If no, Resident Alien Number: Date of Birth – Applicant:
Personal bank accounts carried at (name of financial institution): Co-applicant:
Partner or officer in any other venture?:
Have you or any business you have owned ever declared bankruptcy? Do you have a will?
If yes, please explain on additional sheet. If so, name of executor:
SCHEDULE OF ASSETS PLEDGED
Description Value To Whom Pledged
SCHEDULE A - ALL SECURITIES INCLUDING NON-MONEY MARKET MUTUAL FUNDS
(use additional sheet if necessary)
NO. OF
SHARES OR
BOND FACE
VALUE
DESCRIPTION
OWNER(S)
WHERE HELD
CURRENT MARKET
VALUE
PLEDGED
YES NO
READILY MARKETABLE SECURITIES (including Stocks, Bonds, Mutual Funds, U.S. Governments, and Municipals)
NON-READILY MARKETABLE SECURITIES (thinly traded or restricted stock)
SCHEDULE B – OWNERSHIP IN PRIVATELY HELD BUSINESSES
(use additional sheet if necessary)
BUSINESS NAME
NATURE OF
BUSINESS
DATE OF
INVESTMENT
ORIGINAL
INVESTMENT
COST
% OF
OWNERSHIP
PRESENT VALUE
OF YOUR
INVESTMENT
SCHEDULE C – LIFE INSURANCE
(use additional sheet if necessary)
INSURANCE COMPANY
FACE
AMOUNT
OF POLICY
TYPE OF
POLICY
BENEFICIARY
CASH
SURRENDER
VALUE
POLICY
LOANS
OWNERSHIP
PLEDGED
YES NO
SCHECULE D – REAL ESTATE FOR PERSONAL USE
(use additional sheet if necessary)
PROPERTY ADDRESS
LEGAL
OWNER
PURCHASE
YEAR PRICE
MARKET
VALUE
PRESENT
LOAN
BALANCE
INTEREST
RATE
MATURITY
DATE
MONTHLY
PAYMENT
LENDER
SCHEDULE E - REAL ESTATE INVESTMENTS (MAJORITY OWNERSHIP ONLY)
(use additional sheet if necessary)
PROPERTY ADDRESS
LEGAL
OWNER
PURCHASE
YEAR PRICE
MARKET
VALUE
PRESENT
LOAN
BALANCE
INTEREST
RATE
MATURITY
DATE
MONTHLY
PAYMENT
LENDER
SCHEDULE F - NOTES PAYABLE
TYPE
ORIGINAL
AMOUNT
PRESENT
LOAN
BALANCE
SECURED
COLLATERAL
INTEREST
RATE
MATURITY
DATE
MONTHLY
PAYMENT
LENDER
YES NO
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