Spreadsheet: 016c8314-6383-4ca9-9e84-3f2996b1fb4a
Sheet: Sheet1

PERSONAL FINANCIAL STATEMENT | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10
Submitted to: | Concord Bank |  |  |  |  | Date:
IMPORTANT: Read these directions before completing this Statement
If you are applying for individual credit or if this statement relates to your guaranty of the indebtedness of other person(s), firm(s) or corporation(s) complete all except Section 2.  If you are relying on income from alimony, child support or separate maintenance or on the income or assets of another person as a basis for repayment of the credit requested, provide information in Section 2 about the person whose alimony, support or maintenance payments or income or assets you are relying on.  Alimony, child support, or separate maintenance income, need not be revealed if you do not wish to have it considered as basis for repaying this obligation.
 I intend to apply for individual credit    ________________________________
 |  |  | Applicant (signature)
If you are applying for joint credit, or if this statement relates to your guaranty of the indebtedness of other person(s), firm(s) or corporation(s), complete all sections.
 We intend to apply for joint credit   ___________________________________                        _____________________________________
 |  |  | Applicant (signature) |  |  | Co-Applicant (signature)
 |  | ALL APPLICANTS PLEASE SIGN AND DATE THE BACK OF THIS FINANCIAL STATEMENT.
Section I - Individual Information (type or print) |  |  |  |  | Section 2 - Other Party Information (type or print)
Name |  |  |  |  | Name
Address |  |  |  |  | Address
City, State & Zip |  |  |  |  | City, State & Zip
Social Security |  |  |  |  | Social Security
Date of Birth |  |  |  |  | Date of Birth
Position or Occupation |  |  |  |  | Position or Occupation
Business name |  |  |  |  | Business name
Business address |  |  |  |  | Business address
City, State & Zip |  |  |  |  | City, State & Zip
Length at present address |  |  |  |  | Length at present address
Length of employment |  |  |  |  | Length of employment
[NAME]. phone |  | Bus. phone |  |  | [NAME]. phone |  | Bus. phone
Have (either co you or any firm in which you were a major owner ever declared bankruptcy, or settled
any debts for less than the amounts owed?  If yes, please provide details on a separate sheet. |  |  |  |  |  |  |  |  Yes |  No
Are (either co you a defendant in any suit or legal action? |  |  |  |  |  |  |  |  Yes |  No
Are (either co you presently subject to any unsatisfied judgements to tax liens? |  |  |  |  |  |  |  |  Yes |  No
When, if ever, have (either of you been audited by IRS?
Section 3 - Statement of Financial Condition as of
Assets |  | In dollars |  | If [NAME] | Liabilities |  | In dollars |  | If [NAME]
(Do not include Assets of doubtful value) |  | (omit cents) |  | With |  |  | (omit cents) | (Joint) | With
 |  | (Individual) | (Joint) | Whom |  |  | (Individual) |  | Whom
Cash, Checking & Savings, CD's -see Schedule A |  |  |  |  | Notes payable to banks & others -see Schedule H
U.S. Govt. & marketable securities -see Schedule B |  |  |  |  | Due to brokers
Non-marketable securities |  |  |  |  | Amounts payable to others-secured
Securities held by broker in margin accounts |  |  |  |  | Amounts Payable to others - unsecured
Restricted, control or margin account stocks |  |  |  |  | Accounts & bills due
Real estate owned - see [NAME] |  |  |  |  | Unpaid income tax
Accounts, loans. & notes receivable |  |  |  |  | Other unpaid taxes & interest
Automobiles |  |  |  |  | Real Estate mortgages payable - see Schedules D & H
Cash surrender value life insurance - see Schedule E
Vested interest in deferred compensation/ profit-sharing plans - see [NAME]
Business Venture - see [NAME]
Other assets/personal property itemized - see [NAME] if applicable
 |  |  |  |  | Total Liabilities |  | 0 | 0
 |  |  |  |  | Net Worth |  | 0 | 0
Total Assets |  | 0 | 0 |  | Total Liabilities and Net Worth |  | 0 | 0
Section 4 - Annual Income For Year Ended
Annual Income | (Individual) | (Joint) | Annual Expenditures | (Individual) | (Joint) | Contingent Liabilities Estimated Amounts |  | (Individual) | (Joint)
[NAME], bonuses & commissions |  |  | Mortgage / rental payments |  |  | Do you have any        Yes     No
Dividends & interest |  |  | Real estate taxes & assessments |  |  | Contingent liabilities
 |  |  |  |  |  | (as endorser, co-maker or guarantor?)
Real estate income |  |  | Taxes - federal state & local |  |  | (on leases ? On contracts?)
Other Income - |  |  | Insurance Payments |  |  | Involvement in pending legal actions?
(alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation) |  |  | Other contract payments (car, charge cards, etc) |  |  | Contested income tax liens?
 |  |  | Alimony, child support, maintenance |  |  | Any estimated capital gains tax on the unrealized asset appreciation?
 |  |  | Other Expenses |  |  | Other special debt or circumstances?
Total Income | 0 | 0 | Total | 0 | 0 | If "yes" to any question(s) describe:
 |  |  |  |  |  | Total Contingent Liabilities |  | 0 | 0
([NAME] AND SIGN ON REVERSE SIDE)
SCHEDULE A - CASH, CHECKING AND SAVINGS ACCOUNTS, CERTIFICATES OF DEPOSIT, MONEY MARKET FUNDS, ETC.
Name of Financial Institution |  |  | Type of Account | Owner |  | (J) | If pledged, to whom? |  | Balance
SCHEDULE B - U.S. GOVERNMENT & MARKETABLE SECURITIES (Use additional sheet if necessary)
Number of shares or face value of bonds | Description |  | In Name of |  | Are these Registered, Pledged or Held by others? |  | Market Value | Exchanges where Traded
SCHEDULE C - NON-MARKETABLE SECURITIES (Use additional sheet if necessary)
Number of shares | Description |  | In Name of |  | Are these Registered, Pledged or Held by others? |  | Value | Method of Valuation
SCHEDULE D - INVESTMENTS IN REAL ESTATE (Use additional sheet if necessary)
Description / Location of Real Estate Investment |  | (J) | Date of Original Investment amount | % owned by you | Market Value of your % of Investment | Present Balance | Monthly Payment | Mortgage Maturity Date | Mortgage owed to
SCHEDULE E - LIFE INSURANCE CARRIED, INCLUDING GROUP INSURANCE
Name of Insurance Company |  | Owner of Policy |  | Beneficiary and Relationship |  | Face Amount | Policy Loans |  | Cash Surrender Value
SCHEDULE F - VESTED INTEREST IN DEFERRED COMPENSATION/PROFIT-SHARING PLANS
% Vested | Company Name |  | Account Number | Manner of Payout |  | Distribution Date | Beneficiary |  | Amount
 |  |  |  | (Annuity, [NAME], etc.)
[NAME] (Use additional sheets if necessary)
List Name and Address of any Business Venture In Which You Are a Principal or Partner |  | Your Position / Title in the Business |  | Line of Business | Years in Business | Total Assets Listed in Section 3 | Your % of Ownership | Net Worth of Business | Present Net Value of Your Investment
SCHEDULE H - LOANS OWING BANKS, BROKERS, FINANCE COMPANIES, AND OTHERS (MASTERCARD, VISA, ETC.)
Owing to (Acct #) |  | (J) | Date of Original Borrowing / Amount | Present Balance | Due | Monthly Payment | Date of Final Payment | Secured By
 |  |  |  | CONSENT
Each of the undersigned represents, warrants, and certifies that (1) the information provided herein is true, correct and complete and gives a correct and complete showing of the financial condition of the undersigned, (2) the undersigned has no direct, indirect or contingent liabilities except as set forth in the statement, and (3) legal and equitable title to all assets listed herein is in the undersigned's sole name, except as may be herein otherwise noted.  Each of the undersigned agrees to notify Concord Bank 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) financial condition of any of the undersigned or (3) in the ability of any of the undersigned to perform its (or their) obligation to Concord Bank.
I hereby authorize Concord Bank ("The Bank") to obtain a consumer report or a credit report on me personally with respect to any loan in which I am the borrower, or a principal of the borrower, or a guarantor of the loan.  Such reports may include personal financial, employment and credit information.  "The Bank" may obtain new reports if "The Bank" renews or modifies a loan, or makes a new loan, without being required to get further approval from me.  "The Bank" may disclose any report to any other person or institution who obtains any interest in any loan.  "The Bank" may use the following consent with respect to any new applications for credit that I may make to "The Bank" without getting additional approval from me.
I hereby agree that Concord Bank ("The Bank"), or any employee, agent or representative of "The Bank", may verify all of the information given or credit references.  I hereby authorize any person or company in possession of any such record(s) or information to rely on a photocopy or fax of this consent and to release such records to "The Bank".
If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please contact the Senior Lender at [PHONE], within 60 days from the date you are notified of our decision. We will send you a written statement of reasons for the denial within 30 days of receiving your request for the statement.
NOTICE:  The federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant’s income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning this creditor is FDIC 1100 Walnut Street, Kansas City, MO  64106 Toll-free: (800) 378-9581
APPRAISAL NOTICE:  If the collateral which will secure this loan is a 1-4 family residence, you have the right to a copy of the appraisal used in connection with your application for credit. If you wish to have a copy, please write to us at the address listed below.  We must hear from you no later than ninety (90) days after we notify you about the action taken on your credit application or no later than ninety (90) days after you withdraw your application. Your written request must contain: Applicant's Name, Property Address, Application Date, and mailing instructions for the copy.  We will mail or deliver a copy of the appraisal report to you within 30 days after we receive your request, the report, or reimbursement for the report, whichever is last to occur.
 |  | IMPORTANT INFORMATION ABOUT PROCDURES FOR OPENING A NEW ACCOUNT
To help the government fight the funding of terrorism and money laundering activities, Federal Law requires all financial institutions to obtain, verify and record information that identifies each person who opens an acount.  What this means for you:  When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you.  We may also ask to see your driver's license or other identifying documents.
Date signed |  |  |  | Signature (individual)
Date signed |  |  |  | Signature (individual)