PERSONAL FINANCIAL STATEM ENT
Individual
As of
Joint
20
NameV
Business Phone
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Residence Phone
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&HOOXODU Phone
&LW\6WDWH=LS&RGH
(PDLO$GGUHVV
ASSETS
(Omit Cents)
LIABILITIES
0RQWKO\3PW
Balance
(Omit Cents)
Cash on hand & in Banks
$
Accounts Payable
$
Savings Accounts
$
Notes Payable to Banks & Others
(Describe in Section 2)
$
IRA or Other Retirement Accounts
$
Installment Account (auto)
$
$
Life Insurance-Cash Surrender Value Only
(Complete Section 8)
$
Installment Account (Other)
$
$
Stocks and Bonds(Describe in Section 3)
$
Revolving Accounts
$
$
Real Estate(Describe in Section 4)
$
$
$
Automobile Present Value
$
$
$
Other Personal Property(Describe in Section 5)
$
$
$
Other Assets (Describe in Section 5)
0
$
0
$
0
0
$
Source of Income
Contingent Liabilities
Salary
$
Net Investment Income
As Endorser or Co-Maker
Other Income (Describe below)*
$
Legal Claims & Judgments
$
Real Estate Income
Description of Other Income in Secton 1.
$
$
1HW:RUWK7RWDO$VVHWV7RWDO/LDELOLWLHV
$
Total$VVHWV
Section 2.
Total Liabilities
$
Other Assets (Describe in Section 5)
Section 1.
Mortgages on Real Estate
(Describe in Section 4)
Unpaid Taxes
(Describe in Section 6)
Other Liabilities
(Describe in Section 7)
$
$
$
Provisions for Federal Income Tax
$
$
Other Special Debt
$
*Alimony or Child Support payments need not be disclosed in "Other Income" unless it is desired to have such payments
counted toward total income.
Notes Payable.
Name and Address of Noteholder(s)
Total
Original
Balance
Current
Balance
$
Payment
Amount
0$
0
Frequency
(monthly,etc.)
Security (type of collateral)
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Section 3.
Stocks and Bonds.
# of Shares
Name of Securities
Cost
Market Value
Quotation/Exchange
Date of
Quotation/Exchange
Total Value
$
$
$
Section 4.
0
0
0
(List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part
of this statement and signed.)
Real Estate.
Property A
Property B
Property C
Type of Property
Address of Property
Names Property are listed in
Date Property Purchased
Original Cost of Property
Present Market Value
Name and Address of Mortgage Holder
Mortgage Account Number
Mortgage Loan Balance
Amount of Payment per Month/Year
Status of Mortgage(current or delinquent)
Section 5.
Other Assets.
(Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms of payment and if delinquent,
describe delinquency.)
Section 6.
Unpaid Taxes.
Section 7.
Other Liabilities.
Section 8.
(Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.)
Life Insurance Held
Filed for bankruptcy? Yes
Type: 7
11
13
(Describe in Detail)
(Give face amount and cash surrender value of policies-name of insurance company and beneficiaries)
No
Any unsatisfied judgments?
No
Year: __________ Yes
Are any of the assets listed in this application owned by
a trust? Yes
No
Signatures
I authorize First Utah Bank to make inquiries as necessary to verify the accuracy of the statements made and to determine
my/our creditworthiness. I certify that the statements above and the statements contained in any attachments are true and
accurate as of the stated date(s), These statements are made for the purpose of either obtaining, maintaining or guaranteeing a
loan. You are authorized to answer questions about your credit experience with me/us.
Signature:
Date:
Social Security Number:
Signature:
Date:
Social Security Number:
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