Spreadsheet: 011112cc-5a16-4440-b3ad-1a2b68955ea0
Sheet: Sheet1

PERSONAL FINANCIAL STATEMENT | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7
IMPORTANT: Read these directions before completing this statement.
- 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, complete only Section 1,3 and 4.
- If you are applying for joint credit with another person, complete all Sections, providing information in Section 2 about the joint applicant.
- If you are applying for individual credit but are relying on income from alimony, child support, separate maintenance, or on the income or assets of another
person as a basis for repayment of the credit requested, complete all Sections, providing information in Section 2 about the person whose alimony, support or
maintenance payments or income or assets you are relying.
- If this statement relates to your guaranty of the indebtedness of another person(s), firm(s), or corporation(s), complete [NAME] and 4.
TO: THE BUSINESS BANK OF ST. LOUIS |  |  | E-Mail: |  | Cell Phone:
Section 1 - Individual Information |  |  |  | Section 2 - Other Party Information
Name |  |  |  | Name
Social Security Number |  |  |  | Social Security Number
Date of Birth |  |  |  | Date of Birth
Residence Address |  |  |  | Residence Address
City, State & Zip |  |  |  | City, State & Zip
Business Name |  |  |  | Business Name
Position or Occupation |  |  |  | Position or Occupation
Length of Employment |  |  |  | Length of Employment
Business Address |  |  |  | Business Address
City, State & Zip |  |  |  | City, State & Zip
Residence Phone |  | Business Phone |  | Residence Phone |  | Business Phone
Have (either of) you or any firm in which you were a major owner ever declared bankruptcy, or settled any debt
for less than the amount owed?  If yes, please provide details on a separate sheet. |  |  |  |  |  | Yes        _____ | No      _____
Are (either of) you a defendant in any law suit or legal action? |  |  |  |  |  | Yes        _____ | No      _____
Are (either of) you presently subject to any unsatisfied judgements or tax liens? |  |  |  |  |  | Yes        _____ | No      _____
When, if ever, have (either of) you been audited by IRS?
Section 3 - Statement of financial condition
Assets |  |  | In Dollars | Liabilities |  |  | In Dollars
(do not include assets of doubtful accounts) |  |  | (omit cents) |  |  |  | (omit cents)
Cash on hand and in banks - See Schedule A |  |  |  | Notes payable to banks - See schedule I
US Gov't & Marketable Securities - See Schedule B |  |  |  | Due to brokers - See schedule I
Non-Marketable Securities - See Schedule C |  |  |  | Amounts payable to others - secured
Securities held by broker in margin accounts |  |  |  | Amounts payable to others - unsecured
Restricted or control stocks |  |  |  | Credit Cards and other bills due
Partial interest in Real Estate Equities - see Schedule D |  |  |  | Unpaid income tax
Real Estate owned - see Schedule E |  |  |  | Other unpaid taxes and interest
Accounts, loans, & notes receivable |  |  |  | Real Estate mortgages payable - see Schedule D & E
Automobiles & other personal property |  |  |  | Other debts - Itemize
Cash surrender life insurance - See Schedule F
Vested interest in Deferred Comp. - See Schedule G
Business Ventures - See Schedule H
Other Assets/Personal Property - itemize
 |  |  |  | TOTAL LIABILITIES |  |  | 0
 |  |  |  | NET WORTH |  |  | 0
TOTAL ASSETS |  |  | 0 | TOTAL LIABILITIES AND NET WORTH |  |  | 0
Section 4 - Sources of income for the year ended |  |  |  | Personal Information
[NAME], bonuses, and commissions |  |  | $ | Do you have a will?
Dividends |  |  | $ | If so, name of executor.
Real estate income |  |  | $ | Are you obligated to pay alimony, child support or separate maintenance
Other income (alimony, child support, or separate |  |  | $ | payments?  If so, describe.
maintenance income need not be revealed if you do |  |  | $ | Are any of the above assets held in trust?  If so, which assets and what
not wish to have it considered as a basis for repaying |  |  | $ | type of trust are they held in?
this obligation) |  |  | $ | Are any of your assets pledged other than described on schedules?  If so,
TOTAL |  |  | $ | describe.
Contingent Liabilities |  |  |  | Are you a partner or officer in any other venture other than what is listed
Do you have any contingent liabilities?  If so, describe. |  |  |  | in schedule H?
As endorser, co-maker, or guarantor? |  |  | $ | Income tax settled through date?
On leases or contracts? |  |  | $
Legal claims |  |  | $
Other special debt |  |  | $
Amount of contested income tax liens |  |  | $
[NAME] AND SIGN ON PAGE 2
SCHEDULE A - CASH, CHECKING, SAVINGS, CERTIFICATE 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
Number of shares or face value (bonds) | Description |  |  | In name of |  | If Pledged, to [NAME] | Market Value
SCHEDULE C - NON-MARKETABLE SECURITIES
Number of shares or face value (bonds) | Description |  |  | In name of | If Pledged, to whom | Method of Valuation | Value
SCHEDULE D - PARTIAL INTERESTS IN REAL ESTATE EQUITIES
Address & Type of Property | % of Ownership | Cost | Market Value | Title in Name Of | Date Acquired | Mortgage Maturity | Mortgage Amount
SCHEDULE E - REAL ESTATE OWNED
Address & Type of Property | % of Ownership | Cost | Market Value | Title in Name Of | Date Acquired | Mortgage Maturity | Mortgage Amount
 |  | SCHEDULE F - LIFE INSURANCE CARRIED, INCLUDING GROUP INSURANCE
Name of Insurance Company |  | Owner of Policy |  | Beneficiary and Relationship | Face Amount | Policy Loans | Cash Surrender Value
SCHEDULE G - VESTED DEFERRED COMPENSATION/PROFIT-SHARING PLANS
Name of Company | Account Number |  | Manner of Payout | Distribution Date | Beneficiary | Amount | % Vested
SCHEDULE H - BUSINESS VENTURES (Use additional sheet if needed)
Name and Address of Any Business which you are a partner in | Your Position/   Title in the Business | Line of Business | Years in Business | Total Assets | Your % of Ownership | Net Worth of  Business | Present Net Value of Your Investment
SCHEDULE I - LOANS OWING BANKS, BROKERS, FINANCE COMPANIES, AND OTHERS (Mastercard, Visa, etc.)
Owing to                   (account number) |  | Date of Original Borrowing/  Amount | Present Balance | Due | Monthly Payment | Maturity Date | Secured By
The information contained in this Statement is provided for the purpose of obtaining, or maintaining credit with you 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 in your favor.  Each undersigned
understands that you are 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 complete and that you may consider this Statement as
continuing to be true and correct until a written notice of change is given to you by the undersigned.  You are authorized to make all inquiries you deem
necessary to verify the accuracy of the statements made herein, and to determine my/our creditworthiness.  You are authorized to answer questions about
your credit experience with me/us.
Date Signed: _____________ |  |  |  | Signature (Individual):
Date Signed: _____________ |  |  |  | Signature (Other Party):
Important Security Disclosure: Please DO NOT send any sensitive or confidential information including account numbers, passwords, social security numbers, etc. through an e-mail system. Please fax this completed form to Account Services at (314) 621-0446