Other Assets Readily Convertible to Cash - Itemize

1 CONFIDENTIALS tatement Date:Name:SSN:Address:Birthdate:City, State Zip:Dependents:Home Telephone:Business Telephone:12122232342452562672782892910$ $ $ Worth (Total Assets - Total Liabilities)$ $ $ $ $ any Assets Pledged?As Endorser, Co-maker or Guarantor- YesAre you a Defendant in any Suits or Legal Actions?On Leases or Contracts Have you ever been declared Bankrupt in the last 10 years?Federal - State Income TaxesA CASH IN BANKS AND NOTES DUE TO BANKSType of AccountType of OwnershipNotes Due BanksCOLLATERAL (If any) & Type of OwnershipCash on HandTOTALS$ InformationPERSONAL FINANCIAL STATEMENTS ection IOther Income of Other Person - ItemizeTotalIncome TaxesOther TaxesInsurance PremiumsMortgage PaymentsRent PayableOther ExpensesTotalDividends & InterestRental & Lease Income (Net)

2 Other Income - ItemizeOther Persons Salary, Bonuses & CommissionsTOTAL LIABILITIESTOTAL LIABILITIES & NET WORTHS alary, Bonuses & CommissionsTOTAL ASSETSTOTAL CURRENT LIABILITIESReal Estate Mortgage PayableLiens & Assessments PayableOther Debts - ItemizeCash Rent OwedOther Liabilities Due within 1 Year - ItemizeNotes Due to BanksNotes Due to Relatives & FriendsNotes Due to OthersAccounts & Bills PayableUnpaid Income Taxes Due - Federal StateOther Unpaid Taxes & Interest Loans on Life Insurance PoliciesContract Accounts PayableOther Securities - Not Readily MarketablePersonal PropertyOther Assets - ItemizeCash on Hand & in BanksCash Value of Life Gov.

3 SecuritiesOther Marketable SecuritiesNotes & Accounts Receivable - GoodOther Assets Readily Convertible to Cash - Itemize $ (Explain) Other -Section IIName of BankOn DepositGENERAL INFORMATIONCONTINGENT LIABILITIES(Explain)Legal ClaimsLIABILITIESASSETSANNUAL INCOMEESTIMATE OF ANNUAL EXPENSESTOTAL CURRENT ASSETSReal Estate OwnedMortgages & Contracts OwnedNotes & Accounts Receivable - DoubtfulNotes Due from Relatives & FriendsYesNoYesNoYesNoPERSONAL FINANCIAL STATEMENT1 CONFIDENTIALB LIFE INSURANCE (List only those Policies that you own)CompanyCash Surrender ValuePolicy Loan from Insurance Loans Policy as Collateral$ $ SECURITIES OWNEDFace Value-Bonds No.

4 Of Shares StockType of OwnershipCOSTM arket Value Gov. Value Marketable $ $ NOTES AND ACCOUNTS RECEIVABLE (Money Payable or Owed to You Individually-Indicate by a X if Others have an Ownership Interest)XWhen DueOriginal AmountBalance Due Good AccountsBalance Due Doubtful AccountsBal. Due Notes Rel. & FriendsTOTALS$ $ $ REAL ESTATE OWNED (Indicate by a X if Others have an Ownership Interest)TITLE IN NAME OFDescription & LocationXDate AcquiredOriginal CostPresent Value of Real EstateAmount of Ins. CarriedBal. DuePaymentMaturityTo Whom PayableTOTAL$ $ MORTGAGES AND CONTRACTS OWNED (Indicate by a if Others have an Ownership Interest)ContractMortgageXMaker NameMaker AddressStart DatePaymentMaturityBalance DueTOTALS$ PERSONAL PROPERTY (Indicate by a X if Others have an Ownership Interest)XDate When NewCost When NewValue TodayBalance DueTOTAL$ NOTES ( Other than Bank, Mortgage and Insurance Company Loans) Other Obligors (if any)When DueNotes Due To Rel.

5 & FriendsNotes Due 'Others' (Not Banks)Accounts & Bills PayableContracts PayableTOTALS$ $ $ $ :Signature:Date:SECTION II (Continued)BENEFICIARYI ndicate those Not Registered in Your MARKET VALUE Not Readily Marketable SECURITIESA mount Pledged to Secured Loans$ (if any)Property CoveredDESCRIPTIONTo Whom PayableFor the purpose of procuring credit from time to time, I/We furnish the foregoing as a true and accurate statement of my/our financial condition. Authorization is hereby given to the Lender to verify in any manner it deems appropriate any and all items indicated on this statement.

6 The undersigned also agrees to notify the Lender immediately in writing of any significant adverse change in such financial of PolicyTOTALSMORTGAGE OR CONTRACT PAYABLEPAYABLE TOCOLLATERAL (if any)PERSONAL FINANCIAL STATEMENT1