Personal Financial Statement

Personal Financial Statement Form

Instructions: Please review this entire form before beginning. You may need to enter data not immediately available. Once the form has been sent, you will not be able to go back and make corrections. We suggest printing your completed from before sending. All fields marked with an asterisk (*) are required.

Financial Statement

Date of Financial Statement (MM/DD/YYYY)

Applicant

First Name

Last Name

Suffix

Co-Applicant

First Name

Last Name

Suffix

Assets

Amount in Dollars

Cash - Checking Accounts

Cash - Savings Accounts

College Fund 529

Securities - Stocks/Bonds/Mutual Funds

Notes & Contracts Receivable

Life Insurance (Cash Surrender Value)

Personal Property (Autos, Jewelry, etc.)

Retirement Funds (IRAs, 401ks, etc.)

Real Estate (Market Value)

Other Assets (Please Specify)

Total Assets (Total of All Assets Above)

Liabilities

Amount in Dollars

Current Debt (Credit Cards, Accounts)

Notes Payable (Describe Below)

Taxes Payable

Real Estate Mortgages (Describe Below)

Other Liabilities (Specify)

Total Liabilities (Total of All Liabilities Above)

Net Worth

Amount in Dollars

Net Worth (Total Assets minus Total Liabilities)

Assets-Details

Notes and Contracts Held

From Who Owing

Balance Owing

Total Notes and Contracts Held

Securities: Stocks/Bonds/Mutual Funds

Name of Security

Market Value

Total Securities

Stock in Privately Held Companies

Company Name

Estimated Market Value

Total Stocks

Real Estate

Description/Location

Amount Owing

Market Value

Total Real Estate

Liabilities Details

Credit Card & Charge Card Debit

Name of Card/Creditor

Amount Due

Notes Payable (Excluding Monthly Bills)

Name of Creditor

Amount Owing

Total Notes Payable

Mortgage/Real Estate Loans Payable

Name of Creditor

Amount Owing

Total Mortgages

Endorsement & Signatures

I certify that all information provided by me herein, including attachments (s) is true, correct and complete. I authorize Farmers Savings Bank to make whatever inquiries about me you deem necessary and appropriate for the purpose of evaluating my credit, including obtaining credit reports and contacting my employer. I also authorize Farmers Savings Bank to provide credit information about its credit experience with me to other creditors and credit reporting agencies. I agree to provide any further information the Bank might require to process my application.

Applicant's Signature:

Co-Applicant's Signature