Spreadsheet: 39ecd008-1de2-4e29-9340-8085f0a08dce
Sheet: Financial Statement

 |  |  | FINANCIAL STATEMENT |  |  |  |  |  |  | Personal Background Information:
 |  |  |  | (Agricultural) |  |  |  |  |  | 1. Maritial Status: |  | Married: |  | Unmarried: |  | Separated:
Borrower: |  |  |  |  | Social Security #: |  |  | Birth Date: |  | 2. Ages of Dependents:
Co-Borrower: |  |  |  |  | Social Security #: |  |  | Birth Date: |  | 3. Property Insurance with: |  |  |  |  | Amount $ |  |  | Loss Payable to:
Address: |  |  |  |  | Federal ID#: |  |  |  |  | 4. Crop Insurance with: |  |  |  |  | Amount $ |  |  | Loss Payable to:
 |  |  |  |  | Telephone #: |  |  |  |  | 5. Health Insurance with: |  |  |  |  | Amount $ |  |  | Beneficiary:
County: |  |  |  |  | Statement of Financial Condition as of: |  |  |  |  | 6. Life Insurance with: |  |  |  |  | Amount $ |  |  | Beneficiary:
 | ASSETS: |  |  |  |  | LIABILITIES: |  |  |  | POLICY LOANS:
CURRENT ASSETS |  | (Assets sold during the year) |  | CURRENT | CURRENT LIABILITIES |  | (Amounts due within 1 year) |  | AMOUNT(S) | Name of Policy/Insurance: |  |  |  |  | Cash Value $ |  |  | Policy Loan $ | 0
 |  |  |  | VALUE: | Unsecured  Short Term Debts: |  | (include credit card debt) |  | OWED: | Name of Policy/Insurance: |  |  |  |  | Cash Value $ |  |  | Policy Loan $
Cash &/or Deposits |  |  |  | 0 | Credit Card Balances: |  |  |  | 0 | Name of Policy/Insurance: |  |  |  |  | Cash Value $ |  |  | Policy Loan $
Accounts Receivable |  |  |  | 0
Hedging account equity |  |  |  | 0 |  |  | 0
COMMODITIES FOR SALE OR FEED
(type) | # of units | unit value | [NAME] ? |  | CCC Loans on grain: |  |  |  | 0 | LIST OF MACHINERY/EQUIPMENT:
Corn | 0 | 0 |  |  | (corn) | 0 |  |  |  | Year | Make |  | Model |  |  | Description |  | Prior Liens |  | Value
 | 0 | 0 |  |  | (soybeans) | 0 |  |  |  |  |  |  |  |  |  |  |  |  |  | 0
Soybeans | 0 | 0 |  |  | Rent(s)/Lease(s) |  |  | 0 | 0 |  |  |  |  |  |  |  |  | 0 |  | 0
Wheat | 0 | 0 |  |  | Accounts Payable: (repairs, fuel, fertilizer, etc.) |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0
Hay | 0 | 0 |  |  |  |  |  |  | 0 |  |  |  |  |  |  |  |  |  |  | 0
Prepaid expenses |  | Fuel |  | 0
 |  | Seed |  | 0
 |  | Fertilizer |  | 0 | Taxes Due:
 |  | Chemicals |  | 0 | NOTES TO: | Date due: | Balance: | Interest:
 |  |  |  | 0 | 0 |  | 0 | 0
 |  |  |  | 0
 | LIVESTOCK
(type) | # of units | weight | unit value
 | 0 | 0 | 0
 | 0 | 0 | 0
 | 0 | 0 | 0
 | 0 | 0 | 0
 |  |  |  |  | [NAME] of I.T. debts due in 12 months:
(other current assets) |  |  |  | 0 | Principal Portion of Long Term debts due in 12 months:
TOTAL CURRENT ASSETS |  |  |  |  | TOTAL CURRENT LIABILITIES:
INTERMEDIATE ASSETS |  |  | (Assets not sold within the year) |  | INTERMEDIATE LIABILITIES
BREEDING LIVESTOCK |  | Number | Unit Value |  | (Debts due in more than 1 year and less than 10 years)
 |  | 0 | 0 |  | NOTES TO: | Due Date: | Balance: | Prin. Due:
 |  | 0 | 0 |  |  |  | 0 | 0
 | 0 |  |  | 0
TITLED VEHICLES | 0
MACHINERY: |  |  |  |  |  |  | 0 | 0
Beginning:$ |  | (+)Added: $
(-)Disposed: $ |  | (-) Deprec $
Stocks &/or Bonds: |  |  |  | 0
Retirement Accounts: |  |  |  | 0
Notes Receivable: |  |  |  | 0
Household Goods |  |  |  | 0 |  | Show Total Above
TOTAL INTERMEDIATE ASSETS |  |  |  |  | TOTAL INTERMEDIATE LIABILITIES
LONG TERM ASSETS |  | (Real Estate & Improvements) |  |  | LONG TERM LIABILITIES |  | (Debts due in more than 10 years.)
Owners Name |  | Acres | price/acre |  | NOTES TO: | Due Date: | Balance: | Prin. Due:
0 |  | 0 | 0 |  |  |  | 0 | 0
 | 0 | 0 | 0 |  |  |  | 0
Improvements:
 |  |  |  |  |  | Show Total Above
TOTAL LONG TERM ASSETS |  |  |  |  | TOTAL LONG TERM LIABILITIES
TOTAL ASSETS |  |  |  |  | TOTAL LIABILITIES
Contingent Liabilities with: |  |  |  | $ | NET WORTH | Prior year net worth $ |  |  |  | TITLED VEHICLES AND TRAILERS
Are there any judgements or liens against you? |  |  |  |  | Are you obligated to pay alimony or child support?
Have you been declared bankrupt in the past 10 years? |  |  |  |  | Does anyone else own an interest in the property listed?
Are you a party to lawsuit? |  |  |  |  | If YES, who?    Spouse?   Other?
Are any of your taxes delinquent or in dispute? |  |  |  |  | What property? Describe.____________
Explain any "yes" answers:
To the best of my/our knowledge the foregoing together with any supporting schedule is a true, accurate, and complete statement of my/our financial condition as of the date
shown above. I/We understand that The Farmers Bank, [NAME], IN will retain this statement whether or not credit is approved. Signing below constitutes a request for credit.
 | INDIVIDUAL LOAN REQUEST:  [NAME] for credit in my name alone and relying on my own income &/or assets for repayment.
 | JOINT LOAN REQUEST: Request for credit in our names relying on joint income &/or assets for repayment.
 | SUPPORTED INDIVIDUAL LOAN REQUEST: Request for credit based on the income &/or assets of others for repayment. |  |  |  |  |  |  |  |  |  |  |  |  |  | TOTAL TITLED VEHICLES
Signing below authorizes The Farmers Bank, [NAME], IN to check credit histories and make all inquiries necessary to verify the accuracy of the information contained herein. |  |  |  |  |  |  |  |  |  |  |  |  |  |  | TOTAL EQUIPMENT
 |  |  | SIGNATURE: |  |  |  | SIGNATURE:
DATE SIGNED: