PERSONAL FINANCIAL STATEMENT
AMERICAN INTERSTATE BANK
3331 N 204th Street, Elkhorn, NE 68022
Important: Read these directions before completing this Statement.
If you are applying for individual credit in your own name and are relying on your own income or assets and not the income or assets of another person as the basis for
repayment of the credit requested, complete only Sections 1 and 3.
If you are applying for joint credit with another person, complete all sections, providing information in Section 2 about the joint application.
If you are applying for individual credit, but are relying on income from alimony, child support, or separate maintenance, or on the income or assets of another person as a basis
for repayment of the credit requested, complete all sections, providing information in Section 2 about the person on whose alimony, child support or maintenance payments or
income or assets you are relying.
If this Financial Statement relates to your guaranty of the indebtedness of other person(s), firm(s) or corporation(s), complete Sections 1 and 3
FOR NEW FINANCING OR REFINANCING, PLEASE COMPLETE THIS SECTION
INITIALS
It is my intent to apply for individual credit.
It is our intent to apply for joint credit.
DATE:
LOAN AMOUNT REQUESTED:
Section 1 - Individual Information (Type or Print)
Name:
Residence Address:
City, State & Zip
Position or Occupation:
Business Name:
Business Address:
City, State & Zip
Residence Phone Number:
Business Phone Number:
S.S. No.
DOB:
Section 3 - Statement of Financial Condition as of:
In Dollars
ASSETS
Section 2 - Other Party Information (Type or Print)
Name:
Residence Address:
City, State & Zip
Position or Occupation:
Business Name:
Business Address:
City, State & Zip
Residence Phone Number:
Business Phone Number:
S.S. No.
DOB:
LIABILITIES
In Dollars
(do not include assets of a doubtful value)
Cash on Hand in Banks
U.S. & Marketable Securities ( Sch A.)
Non-Marketable Securities (Sch B.)
Real Estate Owned (Sch C.)
Notes Receivable
Furniture and Fixtures
Notes Payable to Banks - secured
Notes Payable to Banks - unsecured
Notes Payable to Relatives
Unpaid Taxes
Real Estate Mortgages Payable (Sch C.)
Other Debts (Sch. E.)
Automobiles
Cash Value - Life Insurance (Sch D.)
Other Assets - Itemize
Business
American National
Nationwide(co-sign)
TOTAL LIABILITIES
Net Worth
TOTAL ASSETS
TOTAL LIABILITIES & NET WORTH
Sources of Income for Year Ended
Personal Information (Provide details on separate sheet)
Do you have a will? If so, name of executor:
Salary, Bonuses & Commissions:
Are you a partner or officer in any venture? If so describe:
Dividends / Interest Income:
Real Estate / Rental Income:
Are you obligated to pay alimony, child support or separate maintenance
payments? If so describe:
Alimony, child support or separate maintenance received under Court Order, Written
Agreement, Oral Understanding, 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. (If this application is being taken orally, this preceding
statement should be read prior to asking any question concerning income).
Are any assets pledged other than as described on Schedules? If so,
describe.
Other Income:
TOTAL INCOME:
Income Tax Settled Through? (date)
CONTINGENT LIABILITIES
Do you have any contingent liabilities? If so,
describe:
Endorser, co-maker or guarantor?
On leases or contracts?
Are you a defendant in any suits or legal actions?
Most recent tax return year completed:
Yes
No
Other Special Debt?
Total Contingent Liabilities:
Schedule A - Stocks & Bonds - Listed
No. of Shares or
Par Value of
Bonds
Description
Issued in the Name Of:
Cost
Market Value
TOTAL:
Schedule B - Stocks & Bonds - Unlisted
No. of Shares or
Par Value of
Bonds
Description
Issued in the Name Of:
Cost
Market Value
TOTAL:
If yes, give details:
Are you aware of any restrictions dealing with the transfer or sale of the
Yes
No
above securities?
Yes
Are any of your stocks or bonds held in joint tenancy, tenancy in common or community property?
No
Schedule C - Real Estate
Legal Description & Address (also give
brief physical description)
Original
Cost
Title in the Name of:
Current
Market
Value
Trust, Deed, Mortgage or Other Liens
Unpaid
Balance
TOTALS
Is any of the above Real Estate subject to declaration of
Yes
No
homestead?
Monthly
Payment
Is any of your real property held in joint tenancy,
tenancy in common or community property?
Explain:
Schedule D - Insurance
Explain:
Name of Company
Owner of Policy
Beneficiary
Face
Amount
Policy
Loans
Held By:
Yes
No
Cash Surrender Value
TOTALS:
Schedule E - Other Debts
Notes and Accounts
Owed To
Current Amount
Payment
Decription of Security Pledged
TOTALS:
Additional Information
Have you ever failed in business or compromised debts with If Yes, give details:
Yes
No
your creditors?
Are any of your assets pledged, or in any other manner
If Yes, give details:
Yes
No
unavailable for paying debts?
Are there any judgements against you pending?
If Yes, give details:
Yes
No
In the last 14 years, have you been declared bankrupt?
Yes
If Yes, give details:
No
Are there any suits or executions of attachments against you If Yes, give details:
Yes
No
pending?
In the last seven years, have you had property foreclosed
If Yes, give details:
Yes
No
upon or given title or a deed in lieu thereof?
The undersigned acknowledge(s) and understand(s) that the Bank is relying on the information provided herein in deciding whether to grant or continue credit or to accept a
guarantee thereof. Each of the undersigned represents warrants and certifies that the information provided herein is true, correct and complete. Unless the Bank is notified of
any change, it may continue to rely upon the statement herein as true, complete and accurate. The undersigned authorize(s) any person or consumer reporting agency to give the
Bank any information it may have on the undersigned. This personal financial statement shall be considered the Bank's property and not subject to return, based upon the credit
decision.
Signature (Individual)
Printed Name:
DATE:
Signature (Individual)
Printed Name: