Spreadsheet: 3a7a463d-93e4-4c5a-8084-0a22ccae4708
Sheet: Sheet1

 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12 | Unnamed: 13 | Unnamed: 14 | Unnamed: 15 | Unnamed: 16 | Unnamed: 17 | Unnamed: 18 | Unnamed: 19 | Unnamed: 20 | Unnamed: 21 | Unnamed: 22 | Unnamed: 23 | Unnamed: 24 | Unnamed: 25 | Unnamed: 26 | Unnamed: 27 | Unnamed: 28 | Unnamed: 29 | Unnamed: 30 | Unnamed: 31 | Unnamed: 32 | Unnamed: 33 | Unnamed: 34 | Unnamed: 35 | Unnamed: 36 | Unnamed: 37 | Unnamed: 38 | Unnamed: 39 | Unnamed: 40 | Unnamed: 41 | Unnamed: 42 | Unnamed: 43 | Unnamed: 44 | Unnamed: 45 | Unnamed: 46 | Unnamed: 47 | Unnamed: 48 | Unnamed: 49 | Unnamed: 50 | Unnamed: 51 | Unnamed: 52 | Unnamed: 53 | Unnamed: 54 | Unnamed: 55 | Unnamed: 56 | Unnamed: 57
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | PERSONAL FINANCIAL STATEMENT AS OF:
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | SUBMITTED TO:   Farmers & Merchants Savings Bank
PERSONAL INFORMATION
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | APPLICANT
Name:
Home Address:
Home Phone: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Social Security No.: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Date of Birth:
Employer: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Address:
Business Phone No.: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | No. of Years with Employer: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Title/Position:
Name of Previous Employer & Position (If With Current Employer Less Than 3 Yrs):
No. of Years: |  |  |  |  |  |  |  |  |  | Address: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Business Phone No.:
Name of your Accountant: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Business Phone No.:
Name of your Attorney: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Business Phone No.:
Name of your Investment Advisor/Broker: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Business Phone No.:
Name of your Insurance Advisor: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Business Phone No.:
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | CO-APPLICANT
Name:
Home Address:
Home Phone: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Social Security No.: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Date of Birth:
Employer: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Address:
Business Phone No.: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | No. of Years with Employer: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Title/Position:
Name of Previous Employer & Position (If With Current Employer Less Than 3 Yrs):
No. of Years: |  |  |  |  |  |  |  |  |  | Address: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Business Phone No.:
 |  |  |  |  |  |  |  |  |  |  |  | Cash Income & Expenditures Statement for Year Ended |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | (Omit Cents)
 |  |  |  |  | ANNUAL INCOME |  |  |  |  |  |  |  |  |  |  |  |  |  | AMOUNT ($) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | ANNUAL EXPENDITURES |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | AMOUNT ($)
[NAME] (applicant) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Federal Income and Other Taxes
[NAME] (co-applicant) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | State Income and Other Taxes
Bonuses & Commissions (applicant) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Rental Payments, Co-op or [NAME]
Bonuses & Commissions (co-applicant) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Mortgage Payments - Residential
Rental Income |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Mortgage Payments - Investment
Interest Income |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Property Taxes - Residential
Dividend Income |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Property Taxes - Investment
[NAME] |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Interest & Principal Loan Payments
Partnership Income |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Insurance
Other Investment Income |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Investments
Other Income (List)** |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Alimony/Child Support
Gambling |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Tuition
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Other Living Expense
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Medical Expenses
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Other Expenses
TOTAL INCOME |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | TOTAL EXPENDITURES
 | Any significant changes expected in the next 12 months? |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes |  |  |  |  |  | No  (If Yes, Attach information)
 | ** Income from alimony, child support, or separate maintenance income need not be revealed if the applicant or co-applicant does not wish to have it considered as a basis for repaying this obligation.
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Balance Sheet
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | As Of:
 |  |  |  |  |  |  |  |  |  |  |  |  |  | ASSETS |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | LIABILITIES
Cash in this Bank   (including money market account, CDs) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Notes Payable to this Bank Secured
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Notes Payable to this Bank unsecured
Cash in other Financial Institutions (List)( including money market accounts, CD) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Notes Payable to Others (Schedule E)
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Secured
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Unsecured
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Accounts Payable (including credit cards)
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Margin Accounts
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Notes Due:  Partnership (Schedule D)
Readily Marketable Securities ([NAME]) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Taxes Payable
Non-Readily Marketable Securities ([NAME]) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Mortgage Debt (Schedule C1)
Accounts and Notes Receivable |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Invetment Debt ([NAME])
Net Cash Surrender Value of Life Insurance (Schedule B) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Life Insurance Loans (Schedule B)
Residential Real Estate (Schedule C1) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Other Liabilities (List)
Real Estate Investments ([NAME])
Partnerships / PC Interests (Schedule D)
IRA, Keogh, Profit-Sharing & Other Vested Retirement Accts.
Deferred Income (number of years deferred)
Personal Property (including automobiles)
Other Assets (List)
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | TOTAL LIABILITIES
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | NET WORTH
CONTINGENT LIABILITIES |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes |  | No |  |  |  |  | Amount
Are you a guarantor, co-maker, or endorser for any debt of an individual, corporation, or partnership?
Do you have any outstanding letters of credit or surety bonds?
Are there any suits or legal actions pending against you?
Are you contingently liable on any lease or contract?
Are any of your tax obligations past due?
What would be your total estimated tax liability if you were to sell your major assets?
If yes for any of the above, give details:
[NAME] (including U.S. Governments and Municipals)
No. of Shares (Stock) or Face Value (Bonds) |  |  |  |  | Description |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Owners |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Where Held |  |  |  |  |  |  |  | Cost |  |  |  | Current Market Value |  |  |  | Pledged
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes |  | No
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total
[NAME] (closely held, thinly traded, or restricted stock)
No. of Shares (Stock) or Face Value (Bonds) |  |  |  |  | Description |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Owners |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Where Held |  |  |  |  |  |  |  | Cost |  |  |  | Current Market Value |  |  |  | Pledged
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes |  | No
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total
Schedule B - Life Insurance (use additional sheet if necessary)
Insurance Company |  |  |  |  |  |  |  |  |  |  |  | Face Amount of Policy |  |  |  |  |  | Type of Policy |  |  |  |  |  |  | Beneficiary |  |  |  |  |  |  |  |  |  |  |  | Cash Surrender Value |  |  |  |  | Amount Borrowed |  |  |  |  | Beneficiary
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Asset Total |  |  |  |  |  |  |  |  |  |  | Liability Total
Personal Residence & Real Estate Investments, Mortgage Debt (Majority Ownership only)
Schedule C1 - Personal Residence
Property Address |  |  |  |  |  |  |  |  |  |  |  |  |  | Legal Owner |  |  |  |  |  |  |  |  |  |  |  | Purchase |  |  |  |  |  | Market Value |  |  |  |  | Present Loan Balance |  |  |  |  | Interest Rate |  |  | Loan Maturity Date |  |  | Monthly Payment |  |  |  | Lender
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Year |  |  | Price
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total Personal Residence |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total Mortgage Debt
[NAME]
Property Address |  |  |  |  |  |  |  |  |  |  |  |  |  | Legal Owner |  |  |  |  |  |  |  |  |  |  |  | Purchase |  |  |  |  |  | Market Value |  |  |  |  | Present Loan Balance |  |  |  |  | Interest Rate |  |  | Loan Maturity Date |  |  | Monthly Payment |  |  |  | Lender
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Year |  |  | Price
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total Investment |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total Investment Debt
[NAME] (less than majority ownership for real estate partnership)*
Type of Investment |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Date of Initial Investment |  |  |  |  |  |  |  | Cost |  |  |  |  |  |  |  | Percent Owned |  |  |  | Current Market Value |  |  |  |  |  |  |  | Balance Due on Partnerships: Notes, Cash Call |  |  |  |  |  |  |  | Final Contribution Date
Business/Professional (Indicate name):
Investments (Including Tax Shelters):
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total Current Market Value |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total Due
* Note:  For investments which represent a material portion of your total assets, please include the relevant financial statements or tax returns, or in the case of partnership investments or S-corporations, schedule K-1s.
Schedule E - Notes Payable
Due To |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Type of Facility |  |  |  |  |  |  |  |  |  | Amount of Line |  |  |  |  | Secured |  |  |  | Collateral |  |  |  |  |  |  |  | Interest Rate |  |  | Maturity |  |  |  |  |  | Unpaid Balance
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes |  | No
Please Answer The Following Questions:
1 |  | Income tax returns filed through (date): |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Are any returns currently being audited or contested? |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes |  |  |  | No
 |  | If yes, what year(s)?
2 |  | Have (either of) you or any firm in which you were a major owner ever declared bankruptcy? |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes |  |  |  |  | No
 |  | If yes, please provide details:
3 |  | Have you drawn a will? |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes |  |  |  |  | No
 |  | If yes, please furnish the name of the executor(s) and year will was drawn:
4 |  | Number of dependents (excluding self) and relationship to applicant:
5 |  | Did you include two years federal and state tax returns? |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes |  |  |  |  | No
6 |  | Do (either of) you have a line of credit or unused credit facility at any other institution(s)? |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes |  |  |  |  | No
 |  | If so, please indicate where, how much and name of bank:
7 |  | Do you anticipate any substantial inheritances? |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes |  |  |  |  | No
 |  | If yes, please explain:
Representations and Warranties
The information contained in this statement is provided to induce you to extend or to continue the extension of credit to the
undersigned or to others upon the guarantee of the undersigned.  The undersigned acknowledge and understand that you are relying
on the information provided herein in deciding to grant or continue credit or to accept a guarantee thereof. Each of the
undersigned agrees to notify you immediately and in writing of any change in name, address, or employment and of any material
adverse change (1) in any of the information contained in this statement or (2) in the financial condition of any of the
undersigned or (3) in the ability of any of the undersigned to perform its (or their) obligations to you.  In the absence of
such notice or a new and full written statement, this should be considered as a continuing statement and substantially correct.
If the undersigned fail to notify you as required above, or if any of the information herein should prove to be inaccurate or
incomplete in any material respect, you may declare the indebtedness of the undersigned or the indebtedness
guaranteed by the undersigned, as the case may be, immediately due and payable.  You are authorized to make all inquires
you deem necessary to verify the accuracy of the information contained herein and to determine the credit worthiness of the
undersigned.  The undersigned authorize any person or consumer reporting agency to give you any information it may have on
the undersigned.  Each of the undersigned authorizes you to answer questions about your credit experience with the
undersigned.  As long as any obligation or guarantee of the undersigned to you is outstanding, the undersigned shall supply
annually an updated financial statement.  This personal financial statement and any other financial or other information that
the undersigned give you shall be your property.
 |  | Signature |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Signature
Submission of this financial statement and information contained herein consititutes a request for credit in the amount of
$_____________________________________ for the purpose of ______________________________________________
__________________________________________
 |  |  | I intend to apply for individual credit
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Your Signature
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Date
 |  |  | We intend to apply for joint credit
 | Date |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Your Signature
 | Date |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | [NAME]