Spreadsheet: 09e1d1ec-9960-4c4b-932f-37039a9a78d5
Sheet: Sheet1

PERSONAL FINANCIAL STATEMENT
Type of credit for which you are applying - please select below:
 | □ | If you are applying for individual credit in your own name and are relying on your own income or assets and not the income or assets of another person as the basis for repayment of the credit requested.
 | □ | If you are applying for joint credit with another person, provide information where appropriate regarding the joint applicant.
 |  |  |  |  | We intend to apply for joint credit
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Applicant's Initials |  |  |  |  |  |  |  |  |  |  | Co-Applicant's Initials
 | □ | If you are applying for individual credit, but are relying on income from alimony, child support, or separate maintenance, or on the income or assets of another person as the basis for repayment of the credit requested, complete all areas of the application to the extent possible, providing information in the joint applicant section about the person whose alimony, support, maintenance payments, income or assets you are relying.
 |  | Applicant
 | 1. | Name:
 | 2. | Social Security No.: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Date of Birth:
 | 3. | Street Address: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Length of Time:
 | 4. | City: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | State: |  |  |  |  |  |  |  |  |  | Zip Code:
 | 5. | Phone: |  | Home |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Fax:
 |  |  |  | Work
 |  |  |  | Cell
 | 6. | [NAME]:
 | 7. | Employer: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Position/Title:
 | 8. | Employer/Business Address:
 | 9. | Length of Employment: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | [NAME] (optional): |  |  |  |  |  | ○ | Married
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | ○ | Unmarried
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | ○ | Separated
 |  | Co-Applicant* |  |  |  |  |  |  |  |  |  | (*Do not provide this information if your application is for individual credit)
 | 1. | Name:
 | 2. | Social Security No.: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Date of Birth:
 | 3. | Street Address: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Length of Time:
 | 4. | City: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | State: |  |  |  |  |  |  |  |  |  | Zip Code:
 | 5. | Phone: |  | Home |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Fax:
 |  |  |  | Work
 |  |  |  | Cell
 | 6. | [NAME]:
 | 7. | Employer: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Position/Title:
 | 8. | Employer/Business Address:
 | 9. | Length of Employment: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | [NAME] (optional): |  |  |  |  |  | ○ | Married
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | ○ | Unmarried
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | ○ | Separated
Complete the following sections, utilizing the schedules on page 3 to provide detail of your assets and liabilities. The schedules on page 4 should be used if additional space is required.
STATEMENT OF FINANCIAL CONDITION AS OF:                            /                            /  20____
ASSETS |  |  |  |  |  |  |  |  |  |  |  |  |  |  | In Dollars |  |  |  |  | LIABILITIES |  |  |  |  |  |  |  |  |  |  |  |  |  |  | In Dollars
(Do not include Assets of doubtful value) |  |  |  |  |  |  |  |  |  |  |  |  |  |  | (Omit cents) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | (Omit cents)
Cash on hand and in banks |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $ |  |  |  |  | Notes payable to banks - secured - see [NAME] |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $
U S Gov't & Marketable Securities - see Schedule A |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $ |  |  |  |  | Notes payable to banks - unsecured - see [NAME] |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $
Non-Marketable Securities - see Schedule B |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $ |  |  |  |  | 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 Schedule C |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $ |  |  |  |  | Accounts and bills due |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $
Real Estate owned - see [NAME] |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $ |  |  |  |  | Unpaid income tax |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $
Loans Receivable |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $ |  |  |  |  | Other unpaid taxes and interest |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $
Automobiles and other personal property |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $ |  |  |  |  | Real Estate mortgages payable - see [NAME] |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $
Life Insurance cash value - see Schedule E |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $
Other assets - itemize |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $ |  |  |  |  | Other debts - itemize |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | TOTAL LIABILITIES |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | NET WORTH |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $
TOTAL ASSETS |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $ |  |  |  |  | TOTAL LIABILITIES AND NET WORTH |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $
SOURCES OF INCOME FOR YEAR ENDED: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | PERSONAL INFORMATION
[NAME], bonuses & commissions: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Do you have a will? |  |  |  |  |  |  |  |  |  | If so, name executor:
Dividends:
Real Estate income: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Are you a partner or officer in any other venture? If so, describe.
Other income (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):
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Are you obligated to pay alimony, child support or separate maintenance payments? If so, describe.
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Are any assets pledged other than as described on the schedules? If so, describe.
TOTAL |  |  |  |  |  |  |  |  |  |  |  |  |  |  | $ |  |  |  |  | Income tax settled through (date):
CONTINGENT LIABILITIES |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Are you a defendant in any suits or legal actions?
Do you have any contingent liabilities? If so, describe.
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Personal bank accounts carried at:
As endorser, co-maker or guarantor?
On leases or contracts? |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Have (either of you) or any firm for which you were a major owner ever declared (or been forced to declare) bankruptcy, or settled any debts for less than the amounts owed? If so, please provide details on a separate sheet.
Legal claims:
Other special debt:
Amount of contested income tax liens:
DEPOSIT ACCOUNT DETAIL
Name of Financial Institution |  |  |  |  |  |  |  |  |  |  |  |  |  | Type of Account |  |  |  |  |  | Owner |  |  |  |  |  |  |  | Are These Pledged? |  |  |  |  |  | Balance
SCHEDULE A - U.S. GOVERNMENT & MARKETABLE SECURITIES
Number of Shares Or Face Value |  |  |  |  |  | Description |  |  |  |  |  |  |  |  |  |  |  |  |  | In Name Of |  |  |  |  |  |  | Are These Pledged? |  |  |  |  |  | Market Value
SCHEDULE B - NON-MARKETABLE SECURITIES
Number of Shares |  |  |  | Description |  |  |  |  |  |  |  |  |  | In Name Of |  |  |  |  |  |  | Are These Pledged? |  |  |  |  |  | Source of Value |  |  |  |  |  | Value
SCHEDULE C - PARTIAL INTERESTS IN REAL ESTATE EQUITIES (Note if mortgage payments include real estate tax escrow)
Address & Type of Property |  |  |  |  |  |  | Title In Name Of |  |  |  |  |  | % Of Ownership |  |  | Date Acquired |  |  | Cost |  |  |  | Market Value |  |  |  | Mortgage Holder |  |  |  |  | Mortgage Payment |  |  |  | Mortgage Balance
SCHEDULE D - REAL ESTATE OWNED (Note if mortgage payments include real estate tax escrow)
Address & Type of Property |  |  |  |  |  |  |  |  | Title In Name Of |  |  |  |  |  |  | Date Acquired |  |  | Cost |  |  |  | Market Value |  |  |  | Mortgage Holder |  |  |  |  | Mortgage Payment |  |  |  | Mortgage Balance
Homestead
SCHEDULE E - LIFE INSURANCE CARRIED, INCLUDING N.S.L.I AND GROUP INSURANCE
Name of Insurance Company |  |  |  |  |  |  |  |  | Owner of Policy |  |  |  |  |  |  | Beneficiary |  |  |  |  |  | Face Value |  |  |  |  |  | Policy Loans |  |  |  |  |  | Cash Surrender Value
SCHEDULE F - ALL BANKS OR FINANCE COMPANIES WHERE CREDIT IS OUTSTANDING
Name & Address of Lender |  |  |  |  |  |  |  | Credit In The Name Of |  |  |  |  |  |  |  | Collateral |  |  |  |  |  | Original Date |  |  | Payment Amount |  |  |  |  | Current Balance |  |  |  |  | Original Balance
The information contained in this statement is provided for the purpose of obtaining or maintaining credit with Ledyard National Bank on behalf of the undersigned, or persons, firms, or corporations in whose behalf the undersigned may either severally or jointly with others, execute a guaranty. Each undersigned understands that the Bank is relying on the information provided herein (including the designation made as to ownership of property) in deciding to grant or continue credit. Each undersigned represents and warrants that the information provided is true and accurate and that the Bank may consider this statement as continuing to be true and correct until a written notice of change is provided to the Bank by the undersigned. The undersigned authorizes Ledyard National Bank to make all inquiries deemed necessary and to obtain a consumer credit report from any credit reporting agency to verify the accuracy of the statements made herein, in connection with the Bank's preliminary evaluation of undersigned, or during any periodic review of undersigned deemed necessary by the Bank. The undersigned also authorizes Ledyard National Bank to answer questions about credit experience with the undersigned parties.
Date Signed: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Signature (Applicant):
Date Signed: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Signature (Co-Applicant):
SCHEDULE A - U.S. GOVERNMENT & MARKETABLE SECURITIES (CONTINUED)
Number of Shares Or Face Value |  |  |  |  |  | Description |  |  |  |  |  |  |  |  |  |  |  |  |  | In Name Of |  |  |  |  |  |  | Are These Pledged? |  |  |  |  |  | Market Value
SCHEDULE B - NON-MARKETABLE SECURITIES (CONTINUED)
Number of Shares |  |  |  | Description |  |  |  |  |  |  |  |  |  | In Name Of |  |  |  |  |  |  | Are These Pledged? |  |  |  |  |  | Source of Value |  |  |  |  |  | Value
SCHEDULE C - PARTIAL INTERESTS IN REAL ESTATE EQUITIES (CONTINUED)
Address & Type of Property |  |  |  |  |  |  | Title In Name Of |  |  |  |  |  | % Of Ownership |  |  | Date Acquired |  |  | Cost |  |  |  | Market Value |  |  |  | Mortgage Holder |  |  |  |  | Mortgage Payment |  |  |  | Mortgage Balance
SCHEDULE D - REAL ESTATE OWNED (CONTINUED)
Address & Type of Property |  |  |  |  |  |  |  |  | Title In Name Of |  |  |  |  |  |  | Date Acquired |  |  | Cost |  |  |  | Market Value |  |  |  | Mortgage Holder |  |  |  |  | Mortgage Payment |  |  |  | Mortgage Balance
SCHEDULE E - LIFE INSURANCE CARRIED, INCLUDING N.S.L.I AND GROUP INSURANCE (CONTINUED)
Name of Insurance Company |  |  |  |  |  |  |  |  | Owner of Policy |  |  |  |  |  |  | Beneficiary |  |  |  |  |  | Face Amount |  |  |  |  |  | Policy Loans |  |  |  |  |  | Cash Surrender Value
SCHEDULE F - ALL BANKS OR FINANCE COMPANIES WHERE CREDIT IS OUTSTANDING (CONTINUED)
Name & Address of Lender |  |  |  |  |  |  |  | Credit In The Name Of |  |  |  |  |  |  |  | Collateral |  |  |  |  |  | Original Date |  |  | Payment Amount |  |  |  |  | Current Balance |  |  |  |  | Original Balance