Spreadsheet: 884ea50f-4c85-4ad2-a47f-37d300346cfa
Sheet: Sheet1

Please do not leave any questions unanswered.  Use "no" or "none" where necessary. | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Personal Financial Statement | Unnamed: 13 | Unnamed: 14 | Unnamed: 15
 | (Confidential) |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 1 of 2
 |  |  |  | IMPORTANT: Read these directions and check appropriate selection before completing this Statement
 |  |  |  | I am applying for individual credit or to act as individual guarantor for the indebtedness of another party and am relying on my own income or assets and not the income or assets of another party as the basis for repayment of the credit requested. Complete only sections 1 and 3 and all applicable schedules.
 |  |  |  | We are applying for joint credit or to act as joint guarantors for the indebtedness of another party. Complete sections 1, 2 and 3, and all applicable schedules, providing information in Section 2 about the joint applicant or joint guarantor.
 |  |  |  | I am applying for individual credit and will be relying on income from alimony, child support, or separate maintenance or on the income or assets of another individual as the basis for repayment of the credit requested.  [NAME] all sections and applicable schedules, providing information in Section 2 about the individual upon whose alimony, support, or maintenance payments, income or assets you are relying.
 | We intend to apply for joint credit or to act as joint guarantors for the indebtedness of another party:
 | Please sign below (in addition to on page 2) if joint obligation is applicable
 |  |  |  | X |  |  |  |  | X
 |  |  |  |  | Individual (Section 1) |  |  |  |  |  | Other Party (Section 2)
 |  | SECTION 1 - INDIVIDUAL INFORMATION (Type or Print) |  |  |  |  |  |  |  | [NAME] INFORMATION (Type or Print)
 |  | Name |  |  |  |  |  |  |  | Name
 |  | Residence address |  |  |  |  |  |  |  | Residence address
 |  | City, State & Zip |  |  |  |  |  |  |  | City, State & Zip
 |  | Position or occupation |  |  |  |  |  |  |  | Position or occupation
 |  | Business name |  |  |  |  |  |  |  | Business name
 |  | Business address |  |  |  |  |  |  |  | Business address
 |  | City, State & Zip |  |  |  |  |  |  |  | City, State & Zip
 |  | Res. Phone |  |  | Bus. Phone |  |  |  |  | Res. Phone |  | Bus. Phone
 | SECTION 3 - STATEMENT OF FINANCIAL CONDITION
 | ASSETS |  |  |  |  |  | In Dollars |  | LIABILITIES |  |  |  |  | In Dollars
 | (Do not include assets of doubtful value) |  |  |  |  |  | (Omit Cents) |  |  |  |  |  |  | (Omit Cents)
 |  | Cash on hand and in banks - see [NAME] |  |  |  |  | 0 |  |  | Notes payable to banks - secured - see [NAME] |  |  |  | 0
 |  | U.S. Gov't & Marketable Securities - see Schedule B |  |  |  |  | 0 |  |  | Notes payable to banks - unsecured - see [NAME] |  |  |  | 0
 |  | Non-Marketable Securities - see Schedule C |  |  |  |  | 0 |  |  | Due to brokers
 |  | Securities held by broker in margin accounts |  |  |  |  |  |  |  | Amounts payable to others - secured
 |  | Restricted or control stocks |  |  |  |  |  |  |  | Amounts payable to others - unsecured
 |  | Partial interest in real estate equities -  see [NAME] |  |  |  |  | 0 |  |  | Accounts and bills due
 |  |  |  |  |  |  |  |  |  | Unpaid income tax
 |  | Real estate owned - see Schedule E |  |  |  |  | 0 |  |  | Other unpaid taxes and interest
 |  | Loans Receivable |  |  |  |  |  |  |  | Real estate mortgages payable -  see Schedules D and E |  |  |  | 0
 |  | Automobiles and other personal property
 |  | Cash value-life insurance - see [NAME] |  |  |  |  | 0 |  |  | Other debts - itemize
 |  | Business ventures - see Schedule H |  |  |  |  | 0
 |  | Retirement accounts
 |  | Other assets - itemize
 |  |  |  |  |  |  |  |  |  | TOTAL LIABILITIES |  |  |  | 0
 |  |  |  |  |  |  |  |  |  | NET WORTH |  |  |  | 0
 |  | TOTAL ASSETS |  |  |  |  | 0 |  |  | TOTAL LIABILITIES AND NET WORTH |  |  |  | 0
 |  | SOURCES OF INCOME FOR YEAR ENDED: |  |  |  |  |  |  | PERSONAL INFORMATION
 |  | [NAME], bonuses & commissions |  |  |  |  |  |  |  | Do you have a will?  If so, name of executor.
 |  | Dividends
 |  | Real estate income |  |  |  |  | 0 |  |  | Are you a partner or officer in any other venture?  If so, describe.
 |  | Other income (Alimony, child support, or separate maintenance |  |  |  |  | 0
 |  |  | income need not be revealed if you do not wish to have it |  |  |  |  |  |  | Are you obligated to pay alimony, child support or separate maintenance payments?  If so, describe
 |  |  | considered as a basis for repaying this obligation)
 |  |  |  |  |  |  |  |  |  | Are any assets pledged other than as described on schedules?  If so, describe.
 |  | TOTAL |  |  |  |  | 0
 | CONTINGENT LIABILITIES |  |  |  |  |  |  |  |  | Income tax settled through (Year)
 |  | Do you have any of the following contingent liabilities? If so, describe |  |  |  |  |  |  |  | Are you a defendant in any suits or legal actions?
 |  | As endorser, co-maker or guarantor?
 |  | On leases or contracts? |  |  |  |  |  |  |  | Personal bank accounts carried at:
 |  | Legal claims?
 |  | Other special debt?
 |  | Contested income tax liens? |  |  |  |  |  |  |  | Have you ever been declared bankrupt?  If so, describe.
 |  |  |  |  |  |  |  |  |  | Do you have an attorney?  If so, who.
 |  |  |  |  |  |  |  |  |  | Do you have an accountant?  If so, who.
 | Revised December 2012 |  |  |  | ([NAME] schedules and sign on Page 2)
Yes
No