Spreadsheet: 07c0fb9a-4f26-42d4-942e-32054e6342e1
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | (Please enter information in gray shaded areas.) | Unnamed: 3 | Unnamed: 4 | Confidential
Personal Statement
Name |  |  | Spouse's Name
Address | City, State, Zip Code |  | Business Phone | Residence Phone | Cell Phone
E-mail Address (optional) |  |  | Date of Statement
ASSETS | Community Assets and Undersigned's Separate Property | Separate Property of Spouse | LIABILITIES | Of Undersigned | Of Spouse
Cash on hand and in Banks |  |  | Notes payable to Banks-Secured
U.S. Govt. Securities-See Schedule |  |  | Notes payable to Banks-Unsecured
Listed Securities-See Schedule |  |  | Notes payable to relatives
Unlisted Securities-See Schedule |  |  | Notes payable to others
Accounts and Notes Receivable Due from relatives and friends |  |  | Accounts and bills due
Accounts and Notes Receivable Due from others-good |  |  | Unpaid income tax
Accounts and Notes Receivable-Doubtful |  |  | Other unpaid taxes and interest
Real Estate Owned-See Schedule |  |  | Real Estate Mortgages Payable-See Schedule
Real Estate Mortgages Receivable |  |  | Other liens payable
Automobile(s) |  |  | Loans against Life Insurance
Personal Property |  |  | Other debts-Itemize
Cash Value-Life Insurance
Other Assets-Itemize
 |  |  | Total Liabilities of Applicant and Spouse | 0 | 0
 |  |  | Net Worth (Do not include Spouse's Separate Property in First Column) | 0 | 0
TOTAL ASSETS | 0 | 0 | TOTAL LIABILITIES AND NET WORTH | 0 | 0
Annual Income/Sources of Cash                              for                                         (yr.) | Of Undersigned | Of Spouse | Annual Expenditures/Uses of Cash | Of Undersigned | Of Spouse
Salary, Bonus & Commission: |  |  | Mortgage/Rental Payments:
Dividends & Interest: |  |  | Installment Payments (Car loans, Credit cards…)
Real Estate Income: |  |  | Taxes-Federal, State, Local, & Real Estate:
Sale of Assets: |  |  | Insurance Payments
Other Income: |  |  | Other Expenses (Education, Etc….)
 |  |  | Total Expenditures/Uses of Cash | 0 | 0
TOTAL INCOME/Sources of Cash | 0 | 0 | Excess Income/Sources of cash over expenditures/Uses of cash | 0 | 0
General Information
Are either you or your spouse a defendant in any suit of legal actions? |  |  | Are any of you or your Spouse's assets pledged or mortgaged?
 | (If "Yes", explain fully on separate sheet) |  |  | (If "Yes", complete schedule on reverse)
Are there presently any judgments, garnishments or attachments pending against either you or your spouse? |  |  | Have either you are your spouse ever filed bankruptcy?
 |  |  |  | (If "Yes", complete schedule on reverse)
Undersigned's Marital Status:
Has undersigned's spouse executed a declaration reserving income or separate           property?                                                               (If "Yes", attach copy of declaration) |  |  | Personal Information
 |  |  |  | Of Undersigned | Of Spouse
Contingent Liability | Of Undersigned | Of Spouse | Business or Occupation
As [NAME] or Co-maker |  |  | Employer (Name & Address)
On Lease or Contracts |  |  | Years with Present Employer
Legal Claims |  |  | Partner or Officer in any other venture
Provision for Federal Income Taxes |  |  | Date of birth
Other Special Debts |  |  | Social Security Number
0 | 2001
1 | 2002
2 | 2003
3 | 2004
4 | 2005
5 | 2006
6 | 2007
7 | 2008
8 | 2009
9 | 2010
10+ | 2011
 | 2012
 | 2013
 | 2014
 | 2015