Spreadsheet: ed45da1f-7685-42af-aa58-c0901ffe17ff
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12
 |  |  |  |  |  |  | PERSONAL STATEMENT |  |  |  | CONFIDENTIAL
 |  |  |  |  |  |  |  |  | OFFICE:
NAME
NAME
ADDRESS |  |  |  |  |  |  |  |  |  | PHONE
For the purpose of procuring and maintaining credit from time to time in any form whatsoever with the above named Bank, for claims and demands against the undersigned, the undersigned submits the following as being a true and accurate statement of his/her financial condition on the following date, and agrees that if any change occurs that materially reduces the means or ability of the undersigned to pay all claims or demands against him/her, the undersigned will immediately and without delay notify the said Bank, and unless the Bank is so notified it may continue to rely upon the statement herein given as a true and accurate statement of the financial condition of the undersigned as of the close of business.
 |  |  |  |  |  |  |  |  | DATE
 | PLEASE DO NOT LEAVE ANY QUESTIONS UNANSWERED, USE "NO" OR "NONE" WHERE NECESSARY.
ASSETS |  |  |  | In Even Dollars |  |  | LIABILITIES |  |  | In Even Dollars
Cash on hand and in banks |  |  |  | 0 |  |  | Notes payable to banks - secured |  |  | 0
Marketable Securities - Schedule A |  |  |  | 0 |  |  | Notes payable to banks - unsecured |  |  | 0
Non-Marketable Securities - Schedule B |  |  |  | 0 |  |  | Due to Broker |  |  | 0
Securities held by broker in margin accounts |  |  |  | 0 |  |  | Amounts payable to others - secured |  |  | 0
Restricted or controlled stocks |  |  |  | 0 |  |  | Amounts payable to others - unsecured |  |  | 0
Partial Interest in RE Equities - Schedule C |  |  |  | 0 |  |  | Accounts and bills due |  |  | 0
Real Estate Owned - Schedule D |  |  |  | 0 |  |  | Unpaid income tax |  |  | 0
Loan Receivable |  |  |  | 0 |  |  | Other unpaid taxes and interest |  |  | 0
* Automobiles and other personal property |  |  |  | 0 |  |  | Real Estate mortgages payable - Schedule D |  |  | 0
Cash value-life insurance - Schedule E |  |  |  | 0 |  |  | Other debts - itemize: |  |  | 0
* Other assets - itemize: |  |  |  | 0
 |  |  |  |  |  |  | TOTAL LIABILITIES |  |  | 0
 |  |  |  |  |  |  | NET WORTH |  |  | 0
TOTAL ASSETS |  |  |  | 0 |  |  | TOTAL LIABILITIES AND NET WORTH |  |  | 0
Are all bad and doubtful assets excluded from this statement? |  |  |  |  |  |  | If no, explain:
Income taxes settled through what date? |  |  |  |  |  |  | Additional assessments |  | $
ANNUAL SOURCE OF INCOME |  |  |  |  |  |  | PERSONAL AND GENERAL INFORMATION
ALIMONY, CHILD SUPPORT OR MAINTENANCE PAYMENTS NEED NOT BE REVEALED IF YOU DO NOT WISH TO HAVE IT CONSIDERED AS A BASIS FOR REPAYING THIS OBLIGATION. |  |  |  |  |  |  | Employment |  |  | Tel:
 |  |  |  |  |  |  | Address
[NAME], bonus & commissions |  |  |  | 0 |  |  | Do you have a will?
Dividends |  |  |  | 0 |  |  | If yes, name of executor
Real Estate income |  |  |  | 0 |  |  | Are you a partner or officer in any other venture?
Other income |  |  |  | 0
 |  |  |  |  |  |  | Are you obligated to pay alimony, child support, or maintenance payments? If so, describe:
TOTAL |  |  |  | 0
CONTINGENT LIABILITIES |  |  |  |  |  |  | Social Security No.
 |  |  |  |  |  |  | Are any assets pledge?
Do you have any contingent liabilities?
If yes, give details:
 |  |  |  |  |  |  | Are you a defendant in any suits or legal actions?
As endorser, co-maker or guarantor |  |  |  | 0
On leases or contract |  |  |  | 0 |  |  | Personal bank accounts carried at:
Legal claims |  |  |  | 0 |  |  | Have you ever taken bankruptcy? Explain:
Other special debt |  |  |  | 0
Amount of contested income tax liens |  |  |  | 0
*Represents Owner's Evaluations
 |  |  |  |  |  |  |  |  |  |  | CONFIDENTIAL
SCHEDULE A - U.S. GOVERNMENTS AND MARKETABLE SECURITIES
No. of Shares or Face Value (Bonds) |  | Description |  |  |  | In Name of |  |  |  | Market Value | Source of Value
 |  |  |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  | 0
SCHEDULE B - NON-MARKETABLE SECURITIES
Description of Securities |  |  |  | No. of Shares Owned |  | Book Value Per Financial Statement |  |  |  | No. of Shares Outstanding | Total Value
 |  |  |  |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  | 0
SCHEDULE C - PARTIAL INTERESTS IN REAL ESTATE EQUITIES
Location of Property |  |  |  | % of Ownership |  | Type |  | Year of Purchase | Cost / Market | Mortgage | Value of Equity
 |  |  |  |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  | 0
SCHEDULE D - REAL ESTATE OWNED
Address + Property Type - Include R-Residential, C-Commercial, I-Investment, V-Vacation |  |  |  | Cost |  | Date Acquired | Market Value | Amt of Mtgs/Lien | Gross Monthly Rental Income | Monthly Taxes, Ins, Maintenance & Misc | Net Monthly Rental Income | Maturity
Prop Address |  |  |  | 0 |  |  | 0 | 0 | 0 | 0 | 0
Title in Name
Prop Address |  |  |  | 0 |  |  | 0 | 0 | 0 | 0 | 0
Title in Name
Prop Address |  |  |  | 0 |  |  | 0 | 0 | 0 | 0 | 0
Title in Name
Prop Address |  |  |  | 0 |  |  | 0 | 0 | 0 | 0 | 0
Title in Name
Totals |  |  |  | 0 |  |  | 0 | 0 | 0 | 0 | 0
SCHEDULE E - LIFE INSURANCE CARRIED, INCL GROUP INSURANCE
Face Amounts |  | Name of Company |  |  |  |  | Beneficiary |  |  | Cash Surrender Value | Loans
SCHEDULE F - NAME OF BANKS OR FINANCE COMPANIES WHERE CREDIT HAS BEEN OBTAINED
Name and Address |  |  |  |  |  |  |  | Original Date | High Credit | Owe Currently | Secured or Unsecured
 |  |  |  |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  | 0 | 0
This 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 |  |  |  | SIGNATURE
DATE |  |  |  | SIGNATURE
 |  |  | (USE ADDITIONAL SCHEDULES WHEN NECESSARY)
 |  |  |  |  |  |  |  |  |  |  | MEMBER FDIC