PERSONAL FINANCIAL STATEMENT
Date:________________
Submitted to: HOMEBANK, 400 SOUTH MAIN, PALMYRA, MO 63461
Please read these directions before completing this application and check (
) the appropriate box below
□ 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, or if this statement relates to your guaranty of the indebtedness of other person(s), firm(s), or corporations(s), complete Sections 1, 3, 4
and 5.
□ 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. Provide information in Section 2 about the person whose alimony, support, or maintenance payments or
income or assets you are relying on. 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 you are applying for joint credit with another person, please complete all sections, providing information in Section 2 about the joint applicant. You understand that the
bank will evaluate your combined assets in deciding whether to extend the requested credit and that you will be jointly liable if the requested credit is advanced.
W E INTEND TO APPLY FOR JOINT CREDIT: ________________
_________________
APPLICANT
CO- APPLICANT
SECTION 1 - Borrower Information
Name:
Residence Address:
City, State & Zip:
Length at Present Residence:
Date of Birth:
SSN:
Position or Occupation:
Business Name:
Business Address:
E-mail:
Business Phone:
Residential Phone:
Length of Employment:
SECTION 2 - Co-Borrower Information
Name:
Residence Address:
City, State & Zip:
Length at Present Residence:
Date of Birth:
SSN:
Position or Occupation:
Business Name:
Business Address:
E-mail:
Business Phone:
Residential Phone:
Length of Employment:
SECTION 3- Declarations
Have (either of) you or any firm in which you were a
major owner ever declared bankruptcy, or settled any
debts for less than the amounts owned? If yes, please
provide details on a separate sheet(s).
Are (either of) you a defendant in any suit or legal
action?
Are any of (either of ) your assets held in a Trust?
Are (either of) you presently subject to any unsatisfied
judgments or tax liens?
Do (either of) you have a will? If so, name of executor
Are any assets pledged other than as described on
schedules? If so, describe.
Yes
No
Are you a partner or officer in any other venture? If so,
describe:
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Are you obligated to pay alimony, child support or
separate maintenance payments? If so, describe.
Personal bank accounts carried with what financial
institution?
When, if ever have (either of ) you been audited by the
IRS?
Yes
No
Yes
No
Income tax settled through (date):
SECTION 4– Statement of Financial Condition
In Dollars
LIABILITIES
Notes payable to banks (secured):
ASSETS
Cash on hand and in banks:
Marketable Securities (see Schedule A):
Notes payable to banks (unsecured):
Non-Marketable Securities (see Schedule B):
Due to brokers:
IRA/Retirement Accounts:
Amounts payable to others (secured):
Restricted or control stocks:
Amounts payable to others (unsecured):
Partial interest in Real Estate (see Schedule C):
Unpaid income tax:
Real Estate Owned (see Schedule D):
Other unpaid taxes and interest:
Automobiles and other personal property:
Real estate mortgages payable (see Schedule D):
Cash value-life insurance (see Schedule E):
Other debts (itemize):
In Dollars
Other assets (itemize):
Total Assets
0.00
Total Liabilities
0.00
Net Worth
0.00
Total Liabilities & Net Worth
0.00
SECTION 5 - Sources of Income for Year ended:
Annual Income
Individual
Joint
Annual Expenditures
Individual
Joint
Contingent Liabilities
Individual
Joint
Salary, bonuses & commissions:
Mortgage/rental
Payments
Do you have any.. Yes No
Interest/Dividend Income:
Real Estate Taxes &
Assessments:
Contingent Liabilities
(endorser, co-maker,
guarantor?)
Real estate income:
Taxes- Federal, State
and Local
Leases or Contracts?
Other Income (List Source):
Insurance Payments
Involvement in pending legal
action?
Other Contract Payments
(Car, Charge Cards, etc)
Alimony, Child Support,
Maintenance
Contested Income Tax Liens?
Other Special Debt or
Circumstances
Other Expenses
0.00
Total Income
0.00
Total Expenditures
0.00
0.00
Total Contingent Liabilities
0.00
0.00
SCHEDULE A - U.S. GOVERNMENTS & MARKETABLE SECURITIES
Number of Shares
or Face Value
(Bonds)
Description
In Name of
Are These
Pledged?
Market Value
Source of
Value
Value
SCHEDULE B - NON-MARKETABLE SECURITIES
Number of
Shares
Description
Address & Type of
Property
In Name Of
Are These
Pledged?
SCHEDULE C - PARTIAL INTERESTS IN REAL ESTATE
Title in
% Of
Date
Name Of
Ownership
Acquired
Cost
Market
Value
Mortgage
Maturity
Mortgage
Amount
Mortgage
Maturity
Mortgage
Amount
0.00%
0.00%
Address & Type
Of Property
Name of
Insurance Company
SCHEDULE D - REAL ESTATE OWNED
Title in
Date
Name Of
Acquired
Cost
SCHEDULE E - LIFE INSURANCE CARRIED
Owner of
Policy
Beneficiary
Market
Value
Face
Amount
Policy
Loans
SCHEDULE F - BANKS OR FINANCE COMPANIES WHERE CREDIT HAS BEEN OBTAINED
Name & Address
Credit in
Secured or
Original
High
of Lender
The Name Of
Unsecured
Date
Credit
Cash
Surrender
Value
Current
Balance
(USE ADDITIONAL SCHEDULES IF NECESSARY)
The information contained in this statement is provided for the purpose of obtaining, or maintaining credit with you on behalf of the
undersigned, or persons, firms or corporations in whose behalf the undersigned may either severally or jointly with others, execute a
guaranty in your favor. Each undersigned understands that you are relying on the information provided herein (including the designation
made as to ownership of property) in deciding to grant or continue credit. Each undersigned represents and warrants that the information
provided is true and complete and that you may consider this statement as continuing to be true and correct until a written notice of a change
is given to you by the undersigned. You are authorized to make all inquiries you deem necessary to verify the accuracy of the statements
made herein, and to determine my/our creditworthiness. You are authorized to answer questions about your credit experience with me/us.
Borrower:
Date:
Co-Borrower:
Date: