Financial Statement for Proprietorship From_____________________________ Address_________________________________________ Type of Business__________________________________________________________________________ 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 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 TO COMPLETE INFORMATION. ASSETS Thous. Hunds. Cts. CASH on hand and in bank       NOTES RECEIVABLE, from customers (current)       ACCOUNTS RECEIVABLE, from customers (current)       INVENTORY: finished goods (how valued___________________)                        work in process (how valued___________________)                        raw materials    (how valued___________________)                   TOTAL CURRENT ASSETS           INVESTMENTS: BONDS AND STOCKS (list on reverse side)       ACCOUNTS RECEIVABLE, doubtful (face value $__________________)   estimated worth       MACHINERY AND EQUIPMENT (cost______________________)       FURNITURE AND FIXTURES      (cost______________________)       TOWN OR CITY REAL ESTATE (at actual market value)       COUNTRY REAL ESTATE_________________ acres at $__________________       Other Assets (Itemize)                                                                                                                                  TOTAL ASSETS                   SPECIFY ANY OF ABOVE ASSETS PLEDGED AS COLLATERAL   LIABILITIES Thous. Hunds. Cts. NOTES PAYABLE - TRADE       NOTES PAYABLE - BANKS       NOTES PAYABLE - OTHER       ACCOUNTS PAYABLE, not due       ACCOUNTS PAYABLE, past due       ACCOUNTS PAYABLE TO RELATIVES AND FRIENDS       DEPOSITS OF MONEY by relatives, employees and others       LIENS OR ENCUMBRANCES on merchandise or other assets aside from real estate mortgages       MORTGAGES on town or city real estate (due____________________________)       MORTGAGES on country real estate (due_______________________________)       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 OF CUSTOMERS, DISCOUNTED OR SOLD $____________          CONSIGNED GOODS $______________OTHER $_____________       INSURANCE: on merchandise $____________ buildings $______________             machinery $_____________TOTAL INSURANCE____________       BUSINESS LIFE INSURANCE: to whom payable_____________________AMOUNT       BUSINESS RESULTS: ANNUAL SALES for the year ended______________20_____                                or from______________20_____ to______________20_____ GROSS PROFITS on SALES EXPENSE of CONDUCTING BUSINESS NET PROFIT on SALES OTHER INCOME including investments AMOUNT WITHDRAWN from business for personal use AMOUNT CHARGED OFF FOR DEPRECIATION                                           BUILDINGS: cost $_____________ age_______ depreciation______________________________________ Average TERMS on SALES________________ average TERMS on PURCHASES________________ MACHINERY AND EQUIPMENT: cost $____________depreciation $______________________      condition__________________________________________ FURNITURE AND FIXTURES: cost $____________ depreciation $______________________       condition__________________________________________ STATEMENT: Is it based on actual inventory?________ If so, DATE________________________      If not, HOW____________________________________________________________________ VERIFICATION: Have the books been audited by a PUBLIC ACCOUNTANT?__________       If so, NAME and DATE OF AUDIT______________________________________________________ REAL ESTATE SCHEDULE DESCRIPTION NATURE OF IMPROVEMENTS VALUE MORTGAGES EQUITY ASSESSED CASH                                         In WHOSE NAME is TITLE to above real estate recorded?____________________________________ Is real estate held in FEE SIMPLE or LEASEHOLD?_________________________________________ Have you any DELINQUENT TAXES?___________ If so, HOW MUCH?       on REAL ESTATE on $____________________ on PERSONAL PROPERTY $_______________ FEDERAL INCOME TAXES due $________________ STATE INCOME TAXES dues $_________________      OTHER TAXES due? $____________________ LISTED STOCKS AND BONDS OWNED NAME OF CORPORATION LOCATION PAR VALUE ACTUAL VALUE DATE OF LAST DIVIDEND OR INTEREST RATE NATURE OF BUSINESS                                                   HAVE YOU EVER BEEN ADJUDGED A BANKRUPT?______________ IF SO, GIVE PARTICULARS_________________________________________________________ ________________________________________________________________________________ ARE YOU A PARTNER IN ANY FIRM?______HAVE YOU ANY PARTNERS IN THIS BUSINESS?______ JUDGEMENTS 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.) 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_______________________