Financial Statement for Individual From ___________________________________________________________________________________ Occupation ______________________________________________________________________________ To ______________________________________________________________________________________         For the purpose of obtaining loans and discounting paper with you, and otherwise procuring credit from time to time, I furnish you with the following statement and information which is, and is shown by my books to be a true and correct statement of my financial condition on __________________________, 20___. I agree to and will notify you immediately in writing of any materially unfavorable change in my financial condition, and in the absence of such notice, or of a new and full written statement, this may be considered as a continuing statement and substantially correct; and it is hereby expressly agreed that upon application for further credit, this statement shall have the same force and effect as if delivered as an original statement of my financial condition at the time such further credit is requested. NOTE: COMPLETE ALL BLANKS, WRITING "NO" OR "NONE" WHERE NECESSARY ASSETS Thous. Hunds. Cts. Cash on hand and in bank       Savings       Certificates of deposit       Notes receivable       Accounts receivable (less doubtful portion)       Other (specify)___________________)                                 ___________________)       Total Current Assets       Investments: bonds and stocks (list on reverse side)       Cars and trucks       Machinery and equipment      (cost____________________)       Furniture and fixtures              (cost____________________)       Town or city real estate (at actual market value)       Country real estate _____ acres at $__________________       Cash value life insurace $__________________________        Less borrowing $_____________________________       Other Assets (itemize)                         Total Assets             SPECIFY ANY OF ABOVE ASSETS PLEDGED AS COLLATERAL   LIABILITIES Thous. Hunds. Cts. Notes payable - (List)                               Accounts payable, not due       Accounts payable, past due       Amounts payable to relatives and friends       Other (specify) ___________________________________________________)                       ___________________________________________________)             Machinery and equipment      (cost____________________)       Furniture and fixtures              (cost____________________)       Mortgages on town or city real estate (due____________________________)      (Monthly payments $ ____________________________)       Mortgages on country real estate (due____________________________)      (Monthly payments $ ____________________________)       Other Liabilities (itemize)                                 Total Liabilities Net Worth Total Liabilities and Net Worth                   SPECIFY ANY OF ABOVE LIABILITIES SECURED AS COLLATERAL Contingent liability: (NOT included in assets enumerated above) accommodation, exchanged or endorsed paper $_______________________       Notes receivable, discounted or sold $ _____________________       Insurance: on buildings $ _________________               on machinery $ _________________   Total insurance $ __________________       Life insurance $ ___________________       Is the right to change beneficiary reserved? _______________       Salary and bonus for the year ended______________________ 20 _____      or from_____________________ 20_____ to _____________________ 20_____       (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       Income from investments Living expenses (household expenses, rent, etc.) Auto insurance premiums Household goods insurance premiums                           REAL ESTATE SCHEDULE DESCRIPTION JOINTLY HELD NATURE OF IMPROVEMENTS VALUE DATE PURCHASED MORTGAGES YES NO ASSESSED CASH COST                                                                 Is real estate held in fee simple or leasehold? _____________________________________________________ Have you any delinquent taxes? _______                  If so, how much? - on real estate $ ___________________ on personal property $ __________________ Federal income taxes due $______________ State income taxes due $______________ Other taxes due? $______________ LISTED STOCKS AND BONDS OWNED NAME OF CORPORATION NO. OF SHARES CURRENT MARKET VALUE PAR VALUE DATE OF LAST DIV. OR INTER. RATE AND MATURITY                               UNLISTED STOCKS AND BONDS OWNED NAME OF CORPORATION NO. OF SHARES % of Oustanding Shares Held VALUE LOCATION AND NATURE OF BUSINESS RATE AND MATURITY PAR BOOK MARKET                                             Verification: Have you been audited by a public accountant? ______ If so, name and date of audit _____________________ Have you ever been adjudged a bankrupt? ______ If so, give particulars ________________________________ ___________________________________________________________________________________________ Are you a partner in any firm? _____________ Have you any partners in any business? ___________________ Judgments or suits pending against me at this time $ _______________________________________________ Other data __________________________________________________________________________________ ____________________________________________________________________________________________ I, THE UNDERSIGNED, HEREBY CERTIFY AND DECLARE THAT THE ABOVE STATEMENT AND REPRESENTATIONS CONSTITUTE A TRUE AND ACCURATE ACCOUNT OF MY FINANCIAL CONDITION AS OF THE DATE FIRST ABOVE GIVEN. (BEFORE SIGNING, SEE THAT ALL QUESTIONS HAVE BEEN ANSWERED AND ALL BLANKS FILLED.) Number of dependents _____ Age(s) AGE_____ Complete only if making applicaton for a secured loan, joint credit, or if you reside in a community property state. MARRIED UNMARRIED SEPARATED DATE_________________________20____ SIGNATURE__________________________________________ WITNESS___________________________ ADDRESS___________________________________________ SUBSCRIBED AND SWORN TO BEFORE ME THIS________ DAY OF_________________________20_____ SEAL _____________________________________________________ NOTARY PUBLIC IN AND FOR MY COMMISSION EXPIRES______________________20_____   ****** Statements submitted to Federal Reserve Bank must either be signed originals or certified copies. If copies are furnished, the following certificate must be officially signed by the member bank.      WE HEREBY CERTIFY THAT THE FOREGOING IS A TRUE AND CORRECT COPY OF A SIGNED FINANCIAL STATEMENT OF THE ABOVE MENTIONED INDIVIDUAL, FIRM OR CORPORATION NOW ON FILE IN THIS BANK, AND THAT, TO THE BEST OF OUR KNOWLEDGE AND BELIEF, THIS STATEMENT REFLECTS THE TRUE CONDITION OF THE BORROWER. Statements certified by public accountants may, at the discretion of the Management Committee of the Federal Reserve Bank, be accepted. NAME OF MEMBER BANK___________________________________________________ OFFICIAL SIGNATURE____________________________TITLE______________________