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Personal Financial Statement
Note: An individual personal financial statement should be submitted by all persons who will be contractually liable for the repayment of this loan. Please request additional forms when applicable. If this loan is to be made to a business or corporation, please submit a detailed financial statement of that entity also.
Personal Information
Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
Country
Present Address
Own
Rent
Marital Status
Married
Unmarried -( includes Single Divorced or Widowed
Separated
Complete for Secured Loans Only
Dependents
Name
Age
Add
Remove
Previous Address (Complete if less that 2 years at present address)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
Country
Social Security Number
(Required)
Source of Income
Name of Employer
(Required)
Employer Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
Country
How Long have you worked there
Employer Phone
(Required)
Position/Title position
(Required)
Type of Business
(Required)
Income-Monthly
Salary
(Required)
Bonus and Commissions
Dividends and Interest
Net Rental
*Other-Optional-See-Income Remarks
Total
Previous Employer --How long(complete if current job held less than two years)
Position/Title
Type of Business
*Income remarks-Note: Income from Alimony, Child Support, or maitenance payment need not be disclosed unless their consideration is desired.
Assets
Cash and Money on Deposit
Stocks and Bonds
Accounts and Notes Receivable
Cash Value Life Insurance
Deferred Compensation
Pension Funds
Real Estate Owned
Vehicles Owned
Other Personal Property
Other Assets
Total Assets
Liabilities And Net Worth
Notes Payable
Margin Accounts
Monthly Charges
Life Insurance Loans
Unpaid Taxes
Real Estate Mortgage/Leins
Other Debts (Itemize)
Total Liabilities
Net Worth
Total Liabilities and Net Worth
Asset - Liability Details
Unexercised Stock Options
Holder of Option
Qualified Options
Name of Company
No. of Shares
Price PerShare
Total Price
Current Market PerShare
Current Market Total
Expiration Date
Add
Remove
Non-Qualified Options
Name of Company
No. of Shares
Price PerShare
Total Price
Current Market PerShare
Current Market Total
Expiration Date
Add
Remove
Cash - Checking / Now Accounts - Savings Accounts- C'D'S Schedule of Cash Accounts
Name of Depository
Type of Account
Account Number
In Name Of
Approximate Balance
Pledged Yes
Pledged No
Add
Remove
Schedule Of Stocks And Bonds
Number
Description
In Name Of
Market Value
Pledged Yes
Pledge No
Add
Remove
Schedule Of Accounts and Notes Receivable
Number
Description
In Name Of
Market Value
Pledged Yes
Pledge No
Add
Remove
Schedule Of Life Insurance Carried
Name Of Insurance Company
Type
Benefit Value
Beneficiary
Cash Value
Loans Against Cash Values
Add
Remove
Asset - Liability Details
Schedule of Real Estate Owned
Do you need additional fields?
Yes
No
Property Address
Title in Name Of
Name Of Mortgage Holder
Type
Percent Owned
Date Aquired
INDICATE AND CARRY FORWARD TO ASSET/LIABILITY STATEMENT QM.LY YOUR PROPORTIONATE INTERESTS
Purchase price
market Value
Amount of Mortgages and Liens
Gross Annual Rental
Annual Debt Serv
Annual Net Rental
Add
Remove
Title in Name Of
Name Of Mortgage Holder
Property Address
Type
Percent Owned
Date Aquired
INDICATE AND CARRY FORWARD TO ASSET/LIABILITY STATEMENT QM.LY YOUR PROPORTIONATE INTERESTS
Purchase price
market Value
Amount of Mortgages and Liens
Gross Annual Rental
Annual Debt Serv
Annual Net Rental
Add
Remove
Title in Name Of
Property Address
Name Of Mortgage Holder
Type
Percent Owned
Date Aquired
INDICATE AND CARRY FORWARD TO ASSET/LIABILITY STATEMENT QM.LY YOUR PROPORTIONATE INTERESTS
Purchase price
market Value
Amount of Mortgages and Liens
Gross Annual Rental
Annual Debt Serv
Annual Net Rental
Add
Remove
Title in Name Of
Property Address
Name Of Mortgage Holder
Type
Percent Owned
Date Aquired
INDICATE AND CARRY FORWARD TO ASSET/LIABILITY STATEMENT QM.LY YOUR PROPORTIONATE INTERESTS
Purchase price
market Value
Amount of Mortgages and Liens
Gross Annual Rental
Annual Debt Serv
Annual Net Rental
Add
Remove
Schedule Of Notes - Payable
Owed To (Name & Address)
Date Opened
Date Due
Approximate Amount Owed
Secured Yes
Secured No
Add
Remove
Schedule Of Installment Loans/Obligations/Credit References
Purpose & Date Opened
Owed to (Name and Address)
Account Number
Monthly Payment
Balance Owed or Date Paid
Secured Yes
Secured No
Add
Remove
Vested Interest In Deferred Compensation Or Pension Plans
Name Of Company
Amount
Date Available
Payout Basis
Beneficiary
Add
Remove
TAXPAYER IDENTIFICATION NUMBER
(Required)
UNDER PENALTIES OF PERJURY I certify that the above number is my correct taxpayer identification number.
(Required)
I agree
Additional Information and Explanations
Personal Statement
Have you been or are you now (or any property you have owned or now own) subject to or affected by any of the following: (check box if yes to any of these questions and explain on an attached sheet).
Bankruptcy Proceedings (Within previous 7 years).
Personal Judgments
Foreclosure Suits
Mechanic Lien Claims
Federal or State Tax Liens
Unpaid Taxes or Assessments
Liable as Endorser, Co-maker or Guarantor on Any Notes, Leases or Contracts.
Agreements
(Required)
I agree
The Financial Statement, and any schedules, explanations or additional information attached is submitted on behalf of the undersigned for the purpose of procuring, establishing and maintaining credit from time to time with the above named Lender. The undersigned has carefully read the information contained herein and warrants it to be complete, true and correct as of the following date and that the Lender may continue to rely upon this statement as continuing to be true and correct until a written notice of change is given to Lender by the undersigned. Further, the undersigned agrees that this statement shall remain the property of the Lender regardless if credit is extended. The Lender is authorized to make any inquiries deemed necessary to verify the accuracy of the information herein including, but not limited to procuring consumer reports from consumer reporting agencies; obtaining credit information from other financial institutions and extenders of credit, present and past employers, and references.
Date
(Required)
MM slash DD slash YYYY